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THE TBANSACTIONS
OF THE
EDINBURGH OBSTETRICAL SOCIETY
THE TRANSACTIONS
EDINBURGH OBSTETRICAL SOCIETY.
VOL. XXXII.
SESSION 1906-1907.
EDINBURGH: OLIVER AND BOYD,
PUBLISHERS TO THE SOCIETY
19 0 7. ^>/
PRINTED BY OLIVER AND BOYD, TWEEDDALE COURT EDINBURGH.
PREFACE
This, the thirty-second volume of the Society's Transactions,
contains a record of its proceedings during the Session 1906-1907.
In it, as in former volumes, the views brought forward in the
Papers are to be considered as those of the writers themselves,
and not as those of the Society as a body.
The Editor.
October 1907.
%\
EDINBURGH OBSTETRICAL SOCIETY.
OFFICE-BEAKEKS FOE SESSION 1906-1907.
|)rtsibent.
JOHN WILLIAM BALLANTYNE, M.D., F.R.C.P.Ed.
©uc-|^rcsibtnts.
DAVID BERRY HART, M.D., F.R.C.P.Ed.
WILLIAM FORDYCE, M.D., F.R.C.P.Ed.
([Treasurer.
WILLIAM CRAIG, M.D., F.R.C.S.Ed., 71 Bmntsfield Place.
£ecrd aries.
JAMES LAMOND LACKIE, M.D., F.R.C.P.Ed., 1 Randolph Crescent.
GEORGE FREELAND BARBOUR SIMPSON, M.D., F.R.C.S.Ed., F.R.C.P.Ed.,
50 Melville Street.
librarian.
FRANCIS WILLIAM NICOL HAULTAIN, M.D., F.R.C.P.Ed.,
12 Charlotte Square.
Cbitor of ^Transactions.
ANGUS MACDONALD, M.B., F.R.C.S.Ed., 27 Manor Place.
$Vtcmbcrs of Council.
ALEXANDER HUGH FREELAND BARBOUR, M.D., F.R.C.P.Ed.
NATHANIEL THOMAS BREWIS, M.D., F.R.C.P.Ed., F.R.C.S.Ed.
JAMES HAIG FERGUSON, M.D., F.R.C.P.Ed., F.R.C.S.Ed.,
M.R.C.S.Eng.
JOHN MARTIN MUNRO KERR, M.B., CM., Glasgow.
Professor Sir JOHN HALLIDAY CROOM, M.D., F.R.C.S.Ed.,
F.R. C.P.Ed.
SAMUEL SLOAN, M.D., F.F.P. & S.Glas., Glasgow.
WILLIAM MACRAE TAYLOR, M.B., F.R.C.S.Ed.
EDWARD WILLIAM SCOTT CARMICHAEL, M.D., F.R.C.S.Ed.
List of Presidents, Vice-Presidents, Treasurers,
Secretaries, and Librarians of the Society.
PRESIDENTS.
Year.
Year.
Dr William Beilby, .
1840-41
Sir A. R. Simpson,
1882-83
Sir James Y. Simpson, Bart.
1842-57
Dr John Connel
1884-85
Dr John Moir, .
1858-59
Sir J. Halliday Croom,
1886-87
Dr Alex. Keiller,
1860-61
Dr C. E. Underhill, .
1888-89
Dr T. H. Pattison, .
1862-63
Dr D. Berry Hart,
1890-91
Dr T. Graham Weir, .
1864-65
Sir A. R. Simpson,
1892-93
Sir James Y. Simpson, Bart.
1866-67
Dr A. H. Freeland Barbour,
1894-95
Dr John Burn, .
1868-69
Dr Alexander Ballantyne,
1896-97
Dr Charles Bell, .
1870-71
Sir J. Halliday Croom,
1898-99
Dr L. R. Thomson,
1872-73
Dr R. Milne Murray, .
1900-01
Dr Matthews Duncan,
1874-75
Dr James Ritchie,
1902-03
Sir A. R. Simpson,
1876-77
Dr N. T. Brewis,
1904-05
Dr David Wilson,
1878-79
Dr J. W. Ballantyne, .
1906
Dr Angus Macdonald,
1880-81
Sir J. Y. Simpson, Bart..
Dr Alex. Ziegler,
Dr J. Cowan, R.K,
Dr Fairbairn,
Dr Charles Ransford,
Dr R. B. Malcolm,
Dr Charles Bell, .
John Kennedy, Esq.,
Dr John Moir, .
Dr T. H. Pattison,
Dr Beilby, .
Dr T. Graham Weir,
Dr R. B. Malcolm,
Dr John Moir, .
Dr T. Graham Weir,
Dr John Moir,
Dr W. dimming,
Dr A. Thomson, .
Dr T. H. Pattison,
Dr David Wilson,
Dr T. Graham Weir,
Dr George S. Keith,
Dr T. Graham Weir,
Dr Alex. Keiller,
Dr T. H. Pattison,
W. S. Carmichael, Esq.
Dr John Burn. .
Dr Charles Bell, .
Dr William Bryce,
Dr J. A. Sidey, .
Dr William Menzies,
Dr L. R. Thomson,
Sir A. R. Simpson,
Dr J. Matthews Duncan,
Dr Angus Macdonald,
Dr R. Peel Ritchie, .
VICE-PRESIDENTS.
. Year.
1840-41
1840-41
1842
1842
1843
1843
1844
1844
1845-47
1845-47
1848
1848
1849-53
1849-53
1854-55
1854-55
1856-57
1856-57
1858-59
1858-59
1860-61
1860-61
1862-63
1862-63
1864-65
1864-65
1866-67
1866-67
1868-69
1868-69
1870-71
1870-71
1872-73
1872-73
1874-75
1874-75
Year.
Dr James Young,
1876-77
Dr Alex. Milne, .
1876-77
Dr R. Peel Ritchie, .
1878-79
Dr Angus Macdonald, .
1878-79
Sir A. R. Simpson,
1880-81
Dr Robert Bruce,
1880-81
Dr James Carmichael, .
1882-83
Sir J. Halliday Croom,
1882-83
Dr Angus Macdonald, .
1884
Dr Charles E. Underhill,
1884-85
Dr William Ziegler,
1885
Sir A. R. Simpson,
1886-87
Dr Leith Napier,
1886
Dr D. Berry Hart,
1887-88
Dr James Foulis,
1888-89
Dr A. J. Sinclair,
1889
Sir A. R. Simpson,
1890
Dr Peter A. Young, .
1890-91
Dr John Playfair,
1891-92
Dr Freeland Barbour, .
1892-93
Dr A. Ballantyne,
1893-94
Dr James Ritchie,
1894-95
Sir J. Halliday Croom,
1895-96
Sir A. R. Simpson,
1896-97
Dr R. Milne Murray, .
1897-98
Dr N. T. Brewis,
1898-99
Dr J. W. Ballantyne, .
1899-1900
Dr Samuel Macvie,
1900-1901
Dr F. W. N. Haultain,
1901-1902
Dr J. Haig Ferguson, .
1902-1903
Sir A. R. Simpson,
1903-1904
Professor J. A. C. Kynoch. .
1904-1905
Sir J. Halliday Croom,
1905-1906
Dr D. Berry Hart,
1906-1907
Dr William Fordyce, .
1907
vili LIST OF OFFICE-BEARERS
AND HONORARY FELLOWS.
TREASURERS.*
Year.
Year.
Dr Ransford,
1840 to 1842
Dr J. A. Sidey, .
1859 to 1867
Dr G. Paterson, .
1842 to 1847
Dr James Young,
1867 to 1875
Dr Cumming,
1847 to 1854
Dr William Craig,
1875
Dr Keiller, .
1854 to 1859
SECRETARIES.
Year.
Year.
Dr Ransford,
1840 to 1842
Dr Alexander Milne, .
1873 to 1875
Dr G. Paterson, .
1840 to 1847
Dr C. E. Underhill, .
1875 to 1879
Dr Dunsmure,
1842 to 1847
Dr James Carmichael, ,
1875 to 1881
Dr Cumming,
1847 to 1854
Dr D. Berry Hart,
1879 to 1883
Dr Keith, .
1847 to 1849
Dr A. H. Freeland Barbour,
1881 to 1886
Dr J. M. Duncan,
1849 to 1852
Dr R. Milne Murray, .
1883 to 1889
Dr Keiller, .
1852 to 1859
Dr N. T. Brewis, .
1886 to 1893
Dr J. A. Sidey, .
1854 to 1861
Dr J. W. Ballantyne, .
1889 to 1896
Dr A. R. Simpson,
1859 to 1865
Dr F. W. N. Hauitain,
1893 to 1897
Dr Peter Young, .
1861 to 1863
Dr J. Haig Ferguson, .
1896 to 1901
Dr W. Stephenson,
1863 to 1867
Dr William Fordyce, .
1897 to 1904
Dr R. Peel Ritchie,
1865 to 1873
Dr Lamond Lackie,
1901
Dr G. Stevenson Smith,
1867 to 1871
Dr Barbour Simpson, .
1904
Dr James Andrew,
1871 to 1875
LIBRARIANS.
Year.
Year.
Dr J. Jamieson, .
1875 to 1879
Dr R. Milne Murray, .
1889 to 1899
Dr C. E. Underhill, .
1879 to 1883
DrF. W. N. Hauitain,
1899
Dr Peter Young, .
1883 to 1889
EDITORS OF TRANSACTIONS.
Year.
Year.
Dr J. W Ballantyne, .
1896 to 1*99
Dr J. Lamond Lackie, .
1901 to 1905
Dr N. T. Brewis,
1899 to 1901
Dr Angus Macdonald, .
1905
LIST OF
FELLOWS
OF THE SOCIETY.
HONORARY FELLOWS.
1898 Atthill, Lombe, M.D., Monkstown
Castle, Co. Dublin.
1897 Bantock, Dr George Granville, 14
Upper Hamilton Terrace, Lon-
don, N.W.
1901 Bar, Prof. Paul, M.D., Rue la
Boetie, 122, Paris.
1906 Bossi.. Professor L. M., The
University, Genoa.
1886 Bozeman, Dr Nathan, 296 Fifth
Avenue, New York.
1901 Chrobak, Professor R., University of
Vienna.
1898 Coe, Prof. Henry C, M.D., 27 East
Sixty-fourth St., New York.
1898 Cullingworth, Charles J., M.D.,
D.C.L., 14 Manchester Square,
London, W.
1898 Doyen, E., M.D., LL.D., Rue
Piccini, 6, Paris.
1882 Emmet, Dr, 93 Madison Avenue,
New York.
* Previous to 1861 the office of Treasurer was conjoined with that of Senior Secretary.
LIST OF FELLOWS.
IX
1900 Fehling, Professor Herman, M.D., 1 1901
Kaiser Wilhelm's University,
Strassburg.
1882 Freund, Emeritus Professor W., 1 1902
Kleiststrasse, 5, Berlin.
1901 Fritsch, Prof. H., University of 1895
Bonn.
1902 Garrigues, Prof. H. J., Tryon, North 1898
Carolina.
1891 Gusserow, Prof., Charite, Berlin. 1903
1882 Hegar, Professor, Albert Ludwig's
University, Frieburg. 1882
1898 Kelly, Prof. Howard A., M.D.,
Johns Hopkins Hospital, Balti- 1903
more, U.S.A.
1907 Kinoshita, Dr Seichu, Professor of 1906
Obstetrics and Gynaecology, Im-
perial University, Tokio, Japan. 1905
1892 Koeberle, Dr Eugene, Strassburg.
1898 Leopold, Prof. G., M.D., Seminar
Strasse, 25, Dresden. 1901
1906 Makieyeff, Professor Alexander
Matvejevic, The University, | 1876
Moscow.
1895 Martin, Prof. Dr A., N. Greifs-
wald. 1905
1903 Morisani, Professor O., San Felice 1897
a Piazza Dante, 10, Naples.
1892 Miiller, Professor Peter, Berne
Switzerland.
1889 Olshausen, Professor, Frauenklinik
Artillerie Strasse, 13, Berlin.
Ott, Professor D. von, M.D., Pro-
fessor of Obstetrics, University
of St Petersburg.
Pestalozza, Professor, Instituts
Obstetrico Policlinico, Roma.
Pinard, Professor A., Rue Cam-
baceres, 10, Paris.
Pozzi, ProfessorS., M.D., Hopital
Broca, Paris.
Schauta, Professor, Kochgasse, 16,
Vienna.
Schultze, Professor B. S., Univer-
sity, Jena.
Segond, Dr Paul, Quai d'Orsay,
Paris.
Simpson, Emeritus Prof. Sir Alex.
R., LL.D., 52 Queen St.
Sinclair, Prof. Sir William Japp,
Garvock House, Dudley Road,
Manchester.
Sneguireff, Professor W., University
of Moscow.
Turner, Principal Sir W., K.C.B.,
LL.D., D.C.L., 6 Eton Terrace,
Edinburgh.
Veit, Professor, University, Halle.
Williams, Sir John, Bart., M.D.,
LL.D., Plas Llanstephan, Car-
marthenshire.
Winckel, Prof. Von, Ludwig-Maxi-
milian's University, Munich.
Zweifel, Professor, Frauenklinik
University, Leipzig.
CORRESPONDING FELLOWS.
1884 Arnott, Brig. Surg. -Lieut. -Col. Jas.,
8 Rothesay Place.
1887 Baumgartner, Dr H. S., Newcastle-
on-Tyne.
1892 Beilby, Dr J. H., Bromsgrove.
1863 Belgrave, Dr, Sydney.
1888 Bentley, Dr Arthur J., Cairo.
1880 Bosch, Dr Van Den, Liege.
1880 Brock, Dr W. J., Edinburgh.
1863 Brown, Dr R. C, Preston.
1887 Chepmell, Dr C. W. J., London.
1894 Curatulo, Prof. G. E., Rome.
1869 Davies, Mr Thos., Manchester.
1873 Donovan, MrW., Birmingham.
1877 Engelmann, Dr G., Kreuznach.
1896 Eyres, Hugh, Richmond.
1864 Finlay, Right Hon. Sir R. B., M.D ,
LL.D., K.C., London.
1883 Fraser, Dr Dyce, London.
1892 Fraser, Dr Hugh E., Dundee.
1879 Glaister, Prof., Glasgow.
1877 Grassett, Dr F., Toronto.
1868 Grenser, Dr Paul W. T., Dresden.
1864 Greve, Dr, Norway.
1875 Groesbeck, Dr Hermann J., New
York.
1897 Gunsberg, Charkow, Russia.
1853 Hall, Dr D., Montreal.
1870 Haynes, Dr Stanley L., Malvern.
1880 Helme, Dr J. M., Carnforth.
1885 Helme, Dr T. A., Manchester.
1865 Henderson, Dr E., China.
1893 Howard-Jones, Dr J., Newport.
1887 Hume, Dr T., Surgeon-Major, India.
1881 Hurst, Dr George, Australia.
1882 Husband, Dr H. Aubrey, Manitoba.
1893 Hutchison, Dr Robert, London.
1894 Jennings, Dr David D., New York.
LIST OF FELLOWS.
1871 Johnston, Dr A. C, R.N., London.
1882 Johnston, Sur.-Maj. Wilson, India.
1845 Keith, Dr George S., Currie.
1867 Kingston, Dr, Montreal.
1874 Kleinwachter, Prof. L., Gratz.
1871 Lambert, Dr, Paris.
1887 Limont, Dr J., Newcastle-on-Tyne.
1867 Lord, Dr Richard, London.
1878 Macdougall, Dr John A., Cannes.
1879 Machattie, Dr Thomas A., Australia.
1862 Mackay, Dr M. A., Canada.
1870 M'Kendrick, Prof., Stonehaven.
1869 M'Millan, Dr T. L., Australia.
1879 Marshall. Dr Thomas, London.
1866 Martin, Dr Karl, Berlin.
1860 Milburn, Dr George, London.
1883 Mills, Dr B. Langley, India.
1897 Minchin, Dr, Charkow, Russia.
1861 Mitchell, Sir Arthur, LL.D., Edin-
burgh.
1877 Moolman, Dr Henry, South Africa.
1869 Mossop, Mr Isaac, Bradford.
1884 Neve, Dr E. F., Kashmir.
1849 Norris, Mr H., Petherton.
1857 Parker, Dr, Nova Scotia.
1869 Paton, Dr J. W., Bath.
1885 Puckle, Dr S. Hale, Bishop's Castle.
1880 Reid, Dr James More, Aldershot.
1878 Serdukoff, Dr A., St Petersburg.
1887 Shiels, Dr G. F., San Francisco.
1870 Smith, Dr D., Montrose.
1890 Smith, Dr William, America.
1861 Stephenson, Prof. W., Aberdeen.
1888 Stevenson, Sir Edmond Sinclair,
Cape of Good Hope.
1854 Storer, Dr H., Boston, U.S.A.
1875 Sutugin, Dr V., St Petersburg.
1867 Thomson, Mr W., Wrenbury.
1880 Turner, Dr William, Gibraltar.
1885 Underhill, Dr F. T., Vancouver.
1861 Veale, Dr H. R. L., London.
1864 Whiteford, Dr James, Greenock.
1886 Whitton, Dr A. B., Aberchirder.
1865 Wollowicz, Dr C, St Peters-
burg.
ORDINARY FELLOWS.
ARRANGED CHRONOLOGICALLY.
Note.— Those marked with an asterisk have been Members of Council. Members of Council
continue in office two years.
Date of
Admission.
1866
1867
1867
1867
1868
1868
1869
1870
1870
1870
1870
1871
1871
1872
1873
1875
1875
10
15 *
Thomas John Fordyce Messer, M.D., F.F.P. & S. Glasg.,
Garelochhead, ......
John Charles O^ilvie Will, M.D., CM., Aberdeen, .
William Spalding. M.D., M.R.C.S. Eng., Gorebridge, .
George Dickson, M.D., F.R. C.S. Ed., .
♦James Andrew, M.D., F.R.C.P. Ed., .
*William Taylor, M.D., F.R.C.P. Ed., .
James Ormiston Affleck, M.D., F.R. C.S. Ed., F.R.C.P. Ed., .
William Craig, M.D., F.R, C.S. Ed., .
'♦Professor Sir John Halliday Croom, M.D., F.R.C.S. Ed.,
F.R.C.P. Ed.,
'♦Alexander Ballantyne, M.D., F.R.C.P. Ed., Dalkeith,
William Borwick Robertson, M.D., L.R.C.S. Ed., London, .
'♦James Carmichael, M.D., F.R.C.P. Ed.,
'*Peter Alexander Young, M.D., F.R.C.P. Ed., .
'♦Charles Edward Underhill, M.B., P.R.C.P. Ed., F.R.C.S. Ed.,
'♦John Play fair, M.D., F.R.C.P. Ed., Hon. F.R. C.S. Ed.,
'♦Henry Macdonald Church, M.D., F.R.C.P. Ed.,
James Lindsay Howison Herbert Porteous, M.D., F.R.C.S. Ed.,
M.R. C.P.Ed., New York .
LIST OF FELLOWS.
XI
Archibald Bleloch, M.B., Sc.D.,
Joshua John Cox, M.D., F.R.C.S. Ed., Eccles, Manchester,
20 *Thomas Rutherford Ronaldson, M.B., F.R.C.P. Ed., .
Charles H. Thatcher, F.R.C.S. Ed., .
*John Brown Buist, M.D., F.R.C.P. Ed.,
George Herbert Bentley, L.R.C.P. & S.Ed., Kirkliston,
Andrew Douglas Ramsay Thomson, F.R.C.P. Ed., Musselburgh
25 James Stitt Thomson, M.D., F.R.C.P.Ed., F.R.C.S. Ed.,
Lincoln, ......
John Archibald, M.D., F.R.C.S. Ed., Bournemouth, .
*****David Berry Hart, M.D., F.R.C.P. Ed.,
♦David Menzies, M.B., F.R.C.S. Ed., .
Donald Roderick Morrison Murray, M.B., CM., Leith,
30 Robert Spence, M.B., CM., Burntisland, • .
George Mackay, M.B., F.RCS. Ed., .
James Henry Croudace, L.R.C.P. & S. Ed., Stafford, .
Alexander Dinsey Leith Napier, M.D., M.R. C.P.L., Australia
John M'Watt, M.B., CM., Duns,
35 * William Nicol Elder, M.D., L.R.C.P. & S. Ed.,
Henry Hay, M.B., CM., ....
Abraham Wallace, M.D., F.F.P. & S. Glasg., London,
*John Rogerson Hamilton, M.D., CM., Hawick,
George Roth well Adam, M.D., CM., Melbourne,
40*****Alexander Hugh Freeland Barbour, M.D., F.R.C.P. Ed.,
James Murray, M.B., CM., . . .
Andrew James Duncan, M.D., L.R.CS. Ed., Dundee,
T. Edgar Underhill, M.D., F.R.C.S. Ed., Barnt Green,
♦* William Loudon Reid M.D., F.F.P. & S. Glasg., Glasgow,
45 ****James Ritchie, M.D., F.R.C.S. Ed., F.R.C.P. Ed., .
William Alexander Finlay, M.D., F.R.C.S. Ed., Trinity,
James More, M.D., M.R.C.S. Eng., Rothwell, Kettering,
Thomas Rennie Scott, M.D., CM.. Musselburgh,
♦George Hunter, M.D., F.R.C.S. Ed., F.R.C.P. Ed., .
50 John E. Ranking, M.D., F.R.C.P.L., M.R.C.S. Eng., Tun
bridge Wells, .....
♦Arthur Douglas Webster, M.D., F.R.C.P. Ed., .
William Haig Brodie, M.D., F.R.C.S. Eng., M.R.CP.Lon.
London, ......
James Hewetson, M.B., CM., Hohnfield, Reigate,
♦♦Samuel MacYie, M.B.. CM.. Chirnside,
55 John Waugh, M.D., CM., London,
Hugh Logan Calder, M.D., F.F.P. k S. Glasg.,
Henry Anderson Peddie, M.B., CM., .
Thomas Fisher Gilmour, L.R.C.P. Ed.,L F.P. & S. Glasg. , Lslay
Andrew Stark Carrie, M.D., M.R.C.S. Eng., London, .
60 William Black Alexander, L.F.P. & S. Glasg.,
Harry George Deverell, M.D., CM., .
♦George Keppie Paterson, M.B., F.R.C.P.Ed., .
Herbert R. Rendell, M.B., CM., St John's, Newfoundland,
David Smart, M.B., CM., Liverpool, .
65 ♦♦♦Nathaniel Thomas Brewis, M.B., F.R.C.P. Ed., F.R.C.S. Ed
*John William Ballantvne, M.D., F.R.C.P. Ed.,
Thomas Proudfoot, M.B., F.R.C.P. Ed.,
W. Fraser Macdonald, M. B., CM., Glasgow, .
William Spence, M.B., CM., Dollar, .
70 William Wright Millard, M.B., CM.,
John Mowat, M.D., CM.,
James Lumsden Bell, M.B., CM., Driffield, Yorkshire,
*Thomas Brown Darling, M.D., CM., . , ,
Date of
Admission.
1876
1876
1876
1876
1877
1877
1877
1877
1877
1877
1877
1878
1878
1878
1878
1878
1879
1879
1879
1879
1879
1879
1879
1879
1879
1879
1880
1880
1880
1880
1880
1881
1881
1881
1881
1881
1881
1881
1882
1882
1882
1882
1882
1882
1882
1882
1882
1883
1883
1884
1884
1884
1884
1884
1884
1884
Xll
LIST OF FELLOWS.
*Harry Melville Dunlop, M.D., F.R.C.P. Ed., .
75 * Robert William Felkin, M.D., London.
James K. King, M.D., Watkins, New York, .
William Marshall, L.R.C.S. Ed., Milnathort, .
Fourness Barrington, M.B., F.R.C.S. Eng., Sydney, Australia
•Francis William Nicol Haul tain, M.D., F.R.C.P. Ed.,
80 *John Struthers Stewart, L.K.C. P. & S.Ed., .
Frederick Anastasius Saunders, F.R.C.S. Ed., L.R.C.P. Ed.
Grahamstown, South Africa,
John Smith, M.D., M.R.C.S. Eng., Kirkcaldy,
William Gayton, M.D., M.R.C.P.L., M.R.C.S. Eng., London
Gustave Michael, M. B., CM., London, .
85 ** James Haig Ferguson, M.D., F.R.C.P. Ed., M.R.C.S. Eng.
F.R.C.S. Ed., .....
John Edward Gemmell, M.B., CM., Liverpool,
Robert Stewart, M.B., CM., . . .
Surgeon-Captain Robert Charles Macwatt, M.B., B.Sc, CM.
7th Bengal Cavalry, Bombay
*E. H. Lawrence Oliphant, M.D., CM., Glasgow,
90 James Hogarth Pringle, M.B., F.R.C.S. Eng., Glasgow,
John Walton Hamp, L. F. P. & S. Glasg., L.S. A. , Wolverhampton
James Auriol Armitage, M. D. , C M. , Wolverhampton,
William Henry Miller, M.D., F.R.C.P. Ed., .
John M'Call, L.R.C.P. Ed., Portobello,
95 *Thomas Wood, M.D., CM., ....
Hugh M'Callum, L.R.C.P. &S. Ed., Kinloch-Rannoch,
Nutting Stuart Fraser, M.B., M.R.C.S. Eng., St John's, New
foundland, ......
Augustus Alexander Matheson, M.D., F.R.C.P. Ed., .
Robert Mackenzie, M.D., CM., Nairn,
100 Thomas Jackson Thyne, M.B., F.R.C.P. Ed., .
Ernest T. Roberton, M.D., M.R.C.S. Eng., New Zealand,
•Samuel Sloan, M.D., F.F.P. & S. Glasg., Glasgow,
James Wm. Fox, L.R.C.P. &S. Ed., Southampton,
John Frederick Sturrock, M.B., CM., Broughty -Ferry,
105 Alexander Primrose, M.B., M.R.C.S. Eng., Toronto, Canada,
Arthur Per igal, M.D., M.R.C.S. Eng., New Barnet, Herts,
James Aitken Clark, M.B., CM.,
Edward Carmichael, M.D., F.R.C P. Ed.,
Charles Clark Teacher, M.B., CM., North Berwick .
110 Robert Inch, M.B., CM., Gorebridge, .
Ellis Thomas Davies, M.D., M.R.C.S. Eng., Liverpool,
John Orr, M.B., CM., Eccles, Lancashire,
•George Owen Carr Mackness, M.D., CM., Broughty -Ferry,
Francis Joseph Baildon, M.B., CM., Sotcthport,
115 Surgeon-Lt. Ralph H. Maddox, M.B., M.R.C.S. Eng., I.M.S
Bengal, ......
James Williamson Martin, M.D., F.R.C.P. Ed., Dumfries,
James Andrew Blair, M.D., CM., D.Sc, Newcastle-on-Tyne,
•John Thomson, M.D., F.R.C.P. Ed., .
Robert Kirk, M.D., F.R.C.S. Ed., Bathgate, .
120 * William Fraser Wright, M.B., CM., Leith, .
Richard Joseph Tristan, L.R.C.P. & S. Ed., Retford, Notts,
Robert Henry Blaikie, M.D., F.R.C.S. Ed., .
James Hutcheson, M.D., F.R.C.S. Ed., .
A. A. Jervis Pereira, M.D., Delag^a Bay,
125 Christopher Martin, M.B., F.R.C.S. Eng., Birmingham
John George Havelock, M.D., CM., Montrose,
JohnPirie, M.B., CM.
Date of
Admission.
1884
1884
1884
1884
1884
1884
1884
1885
1885
1885
1885
1885
1885
1885
1885
1885
1886
1886
1886
1886
1886
1886
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1887
1888
1888
1888
1888
1888
1888
LIST OF FELLOWS.
Xlll
135
140
145
150
155
160
165
170
175
180
James Gibson Graham, M.B., CM., Glasgow, .
Robert Adams Brewis, M.D., CM., Dursley, .
John Allison, M.D., CM., Kettering, Northampton, .
Archibald Cowan Guthrie, M.B., CM.,
Samuel Beatty, M.B., CM., Pitlochry,
Professor James Chalmers Cameron, M.D., Montreal, .
Albert Edward Morison, M.B., F.R.CS. Ed., M.R.CS. Eng.
West Hartlepool, .....
George H. Temple, M.B., CM., Weston-super-Mare, .
Norman L. Boxill, M.B., CM., Barbados,
John Hunter Helm, M.B., CM., Jiatho,
George Scott MacGregor, M.D., CM., Glasgow,
William Sneddon, M.B., CM., Cupar-Fife, .
Thomas Watts Eden, M.B., CM., London,
* William Fordyce, M.D., F.R.CP. Ed.,
Charles E. Harvey, M.B., M.R.CS. Eng., Sav-la-Mar
Jamaica, . ...
Alexander Lang Murray, L.R.CP. & S. Ed., Australia,
*GeorgePirrie Boddie, M.B., CM., . .
James F. W. Ross, M. 1)., Toronto, Canada,
Hugh Jamieson, M.D., CM., ....
Thomas Wm. Nassau Greene, L.R.CP. Ed., L.R.CS.I
Dublin, ......
Prof. John Clarence Webster, M.D., F.R.CP. Ed., Chicago,
* William George Aitchison Robertson, M.D., F.R.CP. Ed.,
William Basil Orr, M.D., CM.,
* Edward Farr Armour, M.B., CM., .
George Wilkinson, M.D., CM., Liverpool,
* James Lamond Lackie, M.D., F.R.CP. Ed., .
James Wilson, M.B., C.M., ....
Archibald Maclean, M.D., CM., Kilmarnock,
Frederick William Lyle, M.D., CM., London,
Thomas Dobson Poole, M.D., CM., Liuthwaite,
Charles Newberry Cobbett, M.D., CM., Alberta,
Alexander William Gordon Price, M.B., CM.,
Hugh Shapter Robinson, M.R.CS. Eng., L.R.CP. Ed., London
*George Matheson Cullen, M.D., CM.,
Frederick Albert L. Lockhart, M.B., CM., Montreal, Canada
Edmund Frederick Tanney Price, M.B., CM.,
Ernest Theophilus Roberts, M.D., CM., Keighley,
Owen Foulkes Evans, M.D., CM., Liverpool, .
James Duncan Farquharson, M.B., CM., Newcastle- on- Tyne,
Harvey Littlejohn, M.B., F.R.CS. Ed.,
Robert Wise, M.D., CM., London,
William Russell, M.D., F.R.CP. Ed.,
Alexander Scott Duncan, M.B., CM., Polton,
Prof. William Keiller, F.R.CS. Ed., Galveston, Texas, U.S. A
*Michael Dewar, M.D., CM., .
Gains T. Smith, M.D., Moncton, New Brunswick,
John Hugh Alexander Laing, M.B., CM.,
Robert Thin, M.B., F.R.CP. Ed.,
Alexander Henry Vassie, M. B., CM., London,
James Harvey, M.D., CM.,
Alexander Henderson, M.B., CM.,
James Smith, M.D., CM.,
George Balfour Marshall, M.D., CM., Glasgow,
William Booth, F.R.CS. Ed., .
Richard T. Yoe, M.D., Louisville, Kentucky, U.S.A.,
Alexander Bruce Giles, M.D., CM..
Date of
Admission.
1888
1888
1888
1888
1888
1888
1888
1888
1888
1888
1888
1888
1888
1888
1889
1889
1889
1889
1889
1889
1889
1889
1889
1889
1889
1889
1889
1890
1890
1890
1890
1890
1890
1890
1890
1890
1890
1890
1890
1890
1890
1890
1890
1890
1891
1891
1891
1891
1891
1891
1891
1891
1891
1891
1891
1891
XIV
LIST OF FELLOWS.
Hamilton Graham Langwill, M.D., F.K.C.P. Ed., Leith,
185 Herbert Ernest Lee, M.B., CM., Australia,
Charles Martin, M.B., CM., Newton A bbot, .
William Murray Cairns, M.B., CM., Liverpool,
Robert Dundas Helm, M.D., CM., Carlisle, .
James Thomas Moore Giffen, F.R.C.S. Ed., Chester, .
190 Frank Dendle, M.B., D.P.H., Islcworth,
Frederick Thomas Anderson, M.D., F.R.C.S. Ed.,
Simson Carstairs Fowler, M. B., CM., Juniper Green,
Prof. John Alexander Campbell Kynoch, M.B., F.R.C.P. Ed.
Dundee, .
Walter John Shaw, M.B., CM., Cockburnspath,
195 Robert Stirling, M.D., CM., Perth, .
William Henry Vickery, F.R.C.S. Eng., L.R.C.P. Lond.
Weston-super-Mare ....
William Ramsay Smith, M.B., CM., Australia,
Charles Frederick Ponder, M.D., CM., Tasmania,
John Tod, M.B., CM., Leith, .
200 George Henry Walter Smith, M.D., CM., Sydney, Australia
Charles Croomhall Easterbrook, M.D., CM., Ayr,
Walter Petrie Simpson, M. B., CM., Bathgate,
*James Ernest Moorhouse, M.D., CM., Stirling,
D. W. Johnston, F.R.C.S. Ed., Johannesburg, South Africa,
205 David George Davidson, M.B., CM., .
Allen Thomson Sloan, M.D., CM., .
Robert Balfour Graham, F.R.C.S. Ed.,
Albert Frederic Rosa, M.D., CM.,
George Benjamin Mitchell, M.B., CM,
210 Henry Robins, M.D., Jamaica,
Linn J. Schotield, M.D., Warrensburg
George Morton Wilcockson, L.R.C.P. & S. Ed., Reading
John MacRae, M.D., CM., Murray field,
George Wade, M.D., CM., Melrose, .
215 Philip Grierson Borrowman, M.D. , CM., Crieff]
William Herbert Gregory, M.D., CM., Beverley, Forks,
James Gibson Cattanach, M.B., F.R.C.P. Ed.,
Alexander Maitland Easterbrook, M.B., CM., Gorebridge,
Robert William Roberts, L.R.C.P. & S. Ed., North Wales,
220 Claude Buchanan Ker, M.D., F.R.C.P. Ed., .
Charles Alexander Butchart, M.B., CM.,
Frederick Maurice Graham, F.R.C.S. Ed., L.R.C.P. Ed.,
Robert Hoggan, M.B., CM., Liberton,
James Livingstone Thompson, M. B., CM., Australia,
225 John Stevens, M.D., F.R.C.P. Ed., .
Hugh Lewis Hughes, L.R.C.P. & S. Ed., Dowlais,
Sylvaniis Glanville Morris, M.D., CM., Mardy,
Thomas Easton, M.D., CM., Southampton,
David Robertson Dobie, M.D., CM., Crieff, .
230 Gopal Govind Vatve, M.D., Bombay, .
Robert William Beesley, M.D., CM., Bolton, .
William A. Stephen, M.D., CM., Loftus -in- Cleveland,
William Edward Fothergill, M.D., CM., Manchester,
George Sandi son Brock, M.D., CM., Rome.
235 *John Martin Munro Kerr. M.B., CM
John Montgomery, M.B., CM., Birmingham,
*Robert Cochrane Buist, M.D., CM., Dundee, .
Robert Thomson Ferguson, M.B., CM., Anstruther,
Angus Vallance MacGregor, M.D., CM., West Hartlepool,
240 Charles William Donald, M.D., F.R.C.S. Ed., Carlisle,
Leven, Fife, .
, Whitby,
! Mo., U.S.A., '.
Date of
Admission.
1891
1891
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1892
1893
1893
1893
1893
1893
1893
1893
1893
1893
1893
1893
1893
1893
1894
1894
1894
1894
1894
1894
1894
1894
1894
1894
1894
1894
1894
1894
1894
1894
1894
1895
1895
1895
1895
1895
250
255
260
265
270
275
280
285
290
295
LIST OF FELLOWS. XV
Date of
Admission.
John Strutbers, M.B., CM., TransJcei, South Africa, . 1895
B. W. Broad, M.B., CM., Cardiff, .... 1895
Edwin Hindmarsh, M.B., CM., 'Bengal, . . 1895
Patrick Mackin, M.D., F.R.CS. Ed., New Zealand, . . 1895
G. Edgar Helme, M.B., CM., Manchester, . . . 1895
Percy Theodore Hughes, M.B., CM., Broomsgrove, . . 1895
John Hosack Fraser, M.B., F.R.CP. Ed., Bridge of Allan, . 1895
Stewart Grant Ogilvy, M.B., CM., Fauldhouse, . . 1895
Thomas Howard Morgan, M. D., F.R.CS. Ed., Queensland, Aust., 1895
William Macrae Taylor, M.B., F.R.CS. Ed., . . . 1895
David James Graham, M.D., F.R.CP. Ed., . . 1895
Walter William Chipman, M.D., F.R.CS. Ed., Montreal, . 1895
John dimming, M.D., F.R.CS. Ed., F.R.CP. Ed., . . 1896
Sol Jervois Aarons, M.D., CM., London, ... . 1896
Robert Beveridge, M.B., CM., Leith, . . . 1896
John Anderson, M.B., CM., Pitlochry, . . . 1896
Thomas John Burton, M.D., CM., Australia, . . 1896
Robert Gordon M'Kerron, M.B., CM., Aberdeen, . . 1896
Frederick John M'Cann, M.D., M.R.C.P.L., London, . 1896
David Robert Taylor, L.R.C P. & S.Ed., Ayton, . . 1896
George William Simla Paterson, M.B., CM., . . . 1896
Robert Henry Watson, M.D., CM., Hamilton, . . 1896
Thomas Marshall Callender, M.D., CM., Sidcup, . . 1896
Lewis Grant, M.D., CM., Neston, .... 1896
Robert Robertson, M.B., CM., . .... 1897
James Wilkie, L.R.C P. & S. Ed., Portobello, ... 1897
Andrew Graham, M.D., Currie, .... 1897
Roderick Murdoch Matheson, M.D., F.R.CS. Ed., . . 1897
*Robert Jardine, M.D., F.F.P.S. Glasg., M.R.CS. Eng.,
Glasgow, . . . . . . . 1897
Daniel Charles Edington, M.D. , CM., Penrith, . . 1897
John Macmillan, M.D., F.R.CP. Ed., F.R.CS. Ed., . . 1897
Harold Sherman Ballantyne, M.B., CM., Dalkeith, . . 1897
Ernest Edward Porritt, M.D., F.R.CS. Ed., New Zealand, . 1897
William John Garbutt, M.B., CM., Birmingham, . . 1897
Henry John Forbes Simson, M.B., F.R.CS. Ed., London, . 1897
William Alexander Potts, M.D., CM., Birmingham, . . 1897
Angus Macdonald, M.B., F.R.CS. Ed., . . . 1897
Bernard Samuel Story, M.D., F.R.CS. Ed., New Zealand, . 1898
Alexander Macdonald, M.B., F.R.CS. Ed., | . . . 1898
George Robert Livingston, M.D., CM., Dumfries, . . 1898
Charles Carmichael Forrester, M.B., CM., . . . 1898
William Morrison Milne, M.B., CM., . . . . 1898
William Joseph Murphy Barry, M.D., M.R.CP.Ed.,
Penarth, . . . . . . . 1898
John Christie Forbes, L.R.C. P. & S. Ed., Liberton, . . 1898
Alexander Cruikshank Ainslie, M.D.. CM., . . . 1898
Henry Aylmer Dumat, M.D., F.R. C.P.Ed., Durban, South
Africa, . . . . . . . 1898
Gabriel Maurange, M.D., Paris, .... 1898
John Thomas Woodside, L.R.C. P. & S. Ed., Stewartstown, . 1898
George Freeland Barbour Simpson, M.D., F.R.CS. Ed.,
F.R.CP. Ed., 1898
Alfred Charles Sandstein, M.D., Ch.B., New Zealand, . 1898
Alfred Shearer, M.B., Ch.B., Newtown, N. Wales, . . 1898
John Henry Rhodes, M.B., Ch.B., Kendal, . . . 1898
James Duncan Slight, M.D., Ch.B., Leicester, . . . 1898
Francis John Harvey Bateman, M.D., CM., London, . . 1898
Robert John Johnston, M.B., CM., . . . . 1899
XVI
List of fellows.
William Bertie Mackay, M. D. , Berivkk-on- Tweed,
Edward William Scott Carmicliael, M.D., F.R.C.S. Ed..
James Wilson M'Brearty, F.R.C.S. Ed., L.R.CP. Ed., New
Zealand, ......
George Crewdson Thomas, M.D., CM., London,
300 John Eason, M.D., F.R. C.P.Ed., Leith,
William John Barclay, M.D., F.R.C.S., Ed., New Zealand,
Frederick Adolphns Fleming Barnardo, M.B., Ch.B., India,
Alexander Dingvvell Fordyce, M.D., F.R.C.P. Ed., .
William Thomas Ritchie, M.D., F.R.C.P. Ed.,
305 Owen, St John Moses, M.D., CM., B.Sc, Calcutta, .
Charles Wakeham Holmested, L.R.CP. & S. Ed., L.F.P.S
Glasg., Tuxford, .....
Donald MacGregor, M.D., CM., Jedburgh,
*Harry Oliphant Nicholson, M.D., F.R.C.P. Ed.,
Thomas Scott Brodie, M. B., CM., Wishaw, .
310 William Hope Fowler, M.B., Ch.B., .
John Stanley Manford, M.B., B.S., Neivcastle-on-Tyne,
Ogden Watson Ogden, M.D., M.R.C.S., Newcastle-on-Tyne,
John Craig, M.B., Ch.B., ....
William Hartley Bunting, M.D., F.R.C.S. Ed., Birmingham,
315 Theodore Charles Mackenzie, M.B., Ch.B., Aberdeen, .
Donald George Hall, M.B., M.R.C.S. Eng., Sussex, .
Hugh Corbett Taylor Young, M.D., CM., Sydney,
John Boyd Jamieson, M.D., F.R.C.S. Ed.,
Malcolm M'Larty, M.B., CM.,
320 Peter Joseph Henry Ferguson, M.B., CM.,
Frederick Gardiner, M.D., CM.,
George Mackie, M. B., Ch.B., Malvern,
Kenmure Duncan Melville, M.D., Ch.B.,
John Thomas Dickie, L. R. C P. & S. Ed. ,
325 William Ernest Frcst, M.B., Ch.B., .
Frederick David Simpson, M.D., F.R.C.S. Ed.,
Francis Wilfrid Harlin, F.R.C.S. Ed., L.R.CP. Ed., Queens-
land, ......
William Darling, M.B., F.R.C.S. Ed.,
Robert Macfarlane Mitchell, M. B., F.R.C.S. Ed., Australia,
330 Malcolm Campbell, M.B., F.R.C.S. Ed.,
James Ramsay Munro, M. D. , Ch.B., Spalding,
George James Rogerson Carruthers, M.B., Ch.B.,
Hilda Maud M'Farlane, L.R.CP. & S. Ed., Burntisland,
George Dickson, M.D., CM., ....
335 Elsie Maud Inglis, M.B., CM.,
George Robertson. L R.C.P. & S. Ed., Dunfermline,
John Jeffrey, M.B., F.R.C.S. Ed., Jedburgh, .
John Wishart Kerr, M.B., Ch.B., Glasgow,
William Harold Graham Aspland, M.D., M.R.C.S. Eng.
China, ......
340 William Taylor McArthur, M.D., F.R.C.S. Ed., California,
Alexander Waddel Greenhorn Clark, M.B., CM.,
Henry Overton Hobson, M.D., CM., London,.
Robert Patton Ranken Lyle, M.D., Ch.B., Newcastle-on-
Tyne, ......
Frederick William Kerr Tough, L.R.CP. & S. Ed., St Helen'
Junction, Lancashire, ....
345 Robert Ashleigh Glegg, M.D., Ch.B., Leith, .
Walter Scott Patton, M.B., Ch.B., India,
David Whiteside Maclagan, M.B., Ch.B., New Zealand,
Kennedy C M'llwraith, M.B., M.CP. & S. Ont., Toronto,
LIST OF FELLOWS.
XV11
350
35 i
360
365
370
375
380
385
390
395
400
Robert Alexander John Harper, M.D., Ch.B., Dalkeith,
William Hogg Prentice, M.D., Ch.B., Pendleton,
Alexander Mowatt Malcolmson, M.D., Ch.B., Corstorphine,
David Albert Callender, M. B. , Ch. B. , Knutsford,
Caleb Williams Saleeby, M.D., Ch.B., London,
John Andrew Douglas Thompson, Halesowen,
John Ligertwood Green, M. D., Ch.B.,
William Sloss, M.B., Ch.B., Australia,
Charles James Hill Aitken, M.D., CM., Cape Colony,
E. R. Secord, M.D., Ontario, .
F. E. Thompson, M.D., Montreal,
John M 'Gibbon, M.B., CM.,
Thomas James Thomson, M.D., CM.,
Charles Mowbray Pearson, M.B., Ch.B.,
Ewen John Maclean, M.D., M.R.C.P. Lond., Cardiff,
James William Somerville, M.D., CM., Galashiels,
Alexander Miller, L.R.C.P. Ed., L.F.P.S. Glasg., Glasgow,
Hugh Faulkner, M.B., Ch.B , Banbury,
Duncan Macnab Callender, M.B., Ch.B., Lancaster,
Robert Cranston Low, M.B., Ch.B., .
Benjamin Philip Watson, M.B., Ch.B.,
John Macdonald, M.B., CM., Cupar-Fife, .
Mabel Hardie, M. B. , Ch. B, , Stockport,
John Sullivan, M.B., Ch.B., .
Charles William Somerville, M.B., Ch.B., China,
Frank Mayes Willcox, M.B., CM., .
John Tennant, M.B., CM., Scunthorpe,
Alexander Simpson Wells, M.B., F.R.CS. Ed., Cape
Andrew Binny Flett, M.B., Ch.B.,
William Henry Eden Brand, F.R.CS. Ed., L.R.C,
Banchory, ....
Francis Cavanagh, M.B., Ch.B., Sheffield,
Alfred Lambre White, L.R.C.P. & S. Ed., Manchester,
Robert Bathgate Johnston, L.R.C.P. & S. Ed., Penrith
William Llewellyn Jones, M.D., F.R.CS. Ed., Merthyr
Tydvil, ......
Robert Wilson Gibson, M.D., F.R.CS. Ed., Orton, .
Philip Henry Mules, M.B., Ch. B., New Zealand,
Andrea Francis Honyman Rabagliati, M.D. , Ch.B., Bradford
Donald Gregor MacArthur, M.D., CM., Aberfcldy, .
Henry Martyn Stumbles, M. B., Ch.B., Amble,
Gilbert John Farie, M.B., Ch.B., Bridge of Allan,
Cameron Robertson Gibson, M.B., Ch.B., Gretna,
James Mathieson Kirkness, M.D., Ch.B.,
Katherine Jane Stark Clark, M.D., Ch.B., D.P.H., .
David Halliday Croom, M.D., Ch.B., .
Eleanor Russell Elder, M.B., Ch.B., Leith, .
Robert William Johnstone, M.D., Ch. B.,
James William Keay, M.D., Ch.B.,
Ivan Cochrane Keir, M.D., Ch.B., Melksham, .
Alexander Grant Macdonald, M.B., CM.,
Charles John Shaw, M.D., Ch.B., Montrose, .
Frederick Porter, M.B., CM., ....
Sherwin Gibbons, M.D., Los Angeles,
Russell Gerald William Adams, M.D. , Ch.B., New Zealand,
Duncan Campbell Lloyd Fitzwilliams, M.D., Ch.B,
London, .
Clarence Brian Dobell, M.B., M.R.C.S. Eng., M.R.C.P.L,
Cheltenham, .....
Town
P.Ed
Date of
Admission.
1901
1901
1901
1901
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1902
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1903
1904
1904
1904
1904
1904
X.V111
LIST OF FELLOWS.
405
410
415
420
425
430
435
440
445
450
455
460
Hugh Stevenson Davidson, M.B. , Ch.B.,
Andrew Milroy Fleming, C.M.G., M.B., F.R.C.S. Ed
Rhodesia, .....
Thomas William Edmondston Ross, M.B., Ch.B., Cardiff,
John Benjamin Hellier, M.D., M.R.C.S. Eng., Leeds, .
John Thomas Williams, M. D. , Treharris,
William Brown, M.B., Ch.B., Braemar,
John Hepburn Lyell, M.D., CM.. Perth,
Henry Hugh Robarts, M.D., Ch.B., Haddington,
Thomas Garnet Stirling Leary, M.B., Ch.B., Australia,
Robert Balfour Barnetson, M.B. , Ch.B., Portobello, .
James Lochhead, M.D., Ch.B., Earlston,
Arthur Charles Strain, M.D., Ch.B., West Hartlepool,
Lewis Beesly, L.R. C.P.Ed., F.R.C.S. Ed.,
James Crawford Gibb Macnab, M.B., F.R.C.S. Ed., Dysart,
Andrew Alexander Hall, M.B., Ch.B., .
Robert William Lessel Wallace, M.B., Ch.B., Bournemouth,
Alfred Thom Gavin, M.B., CM., Dunaskin, .
Alastair MacGregor, M.D., CM., Market Harborough,
Edmond Frost, M.D., CM., Eastbourne,
Edith Cochrane- Brown Pitts, M.B., Ch.B., New Zealand,
James Brownlee, M.D., Ch.B., Middlesbrough,
William Joseph Maloney, M.D., Ch.B., Cairo,
Peter M'Ewan, M.B., Ch.B., Bradford,
George Douglas Mathewson, M.B., Ch.B.,
Henry Grey Brown, M.B., Ch.B.,
Richard James Harley, M.D., L.R.C.P. &S.Ed., Murruyjirld
Andrew Fleming, M.B., Ch.B., Corstorphine,
Robert William Craig, M.D., Ch.B., Ford,
Henry John Dunbar, M.D., Ch.B., .
Richard Alfred Blake, M.D., Ch.B., Pretoria, South Africa,
John Herbert Gibbs, F.R.C.S. Ed.,
Alice Marion Hutchison, M.D., Ch.B.,
Barbara Martin Cunningham, M.B., Ch.B., India,
W. T. Chouhall, M.D., Sydney,
Alexander Angus Martin, F.R.C.S. Ed., North Shields,
James Andrew Gunn, M.D., Ch.B.,
James Lawson Russell, M.B., Ch.B., Todmorden.
Archibald M'Kendrick, L.R.C.P. k S.Ed., Kirkcaldy,
Alexander Scott, M.B., CM., Broxburn,
Archibald Simpson, M.B., Ch.B., Darlington,
Hirjee Nowon Anklesaria, L.R.C.P. & S.Ed., Bombay,
Archibald Cotterell M 'Master, M.B., Ch.B. .
Arthur James Lewis, M.B. , Ch.B.,
Herbert Park Thompson, M.D., Ch.B.,
Samuel Davidson, M.D., CM., Kelso,
William Fowler Godfrey, M.B., CM.,
H. St John Randell, M. B., Ch. B., Cape Colony,
Kaikhuson Dadabhoy, F.R.C.S. Ed., L.R. C.P.Ed., India,
William Joseph Baird, M.B., Ch.B., Earls Barton, .
Edward Burnet, M.B., Ch.B., .
Arthur Samuel Walker, M.B., Ch.B., Ashley,
Archibald Dunlop Stewart, M. B. , L. R. C S. Ed. ,
Henry Fleet Gordon, M.D., L.R.C.P. & S. Ed., Winnipeg,
Edward Alexander Elder, M.B., Ch.B.,
Ethelbert William Dyer, M. B., Ch.B. , London,
William Torrance Smith, M.B., Ch.B., Midcalder, .
Arnold Davies, M.B., Ch.B., Menai Bridge, .
Thomas Graham Brown, M.B., Ch.B.,
Date of
Admission.
1904
1904
1904
1904
1904
1904
1904
1904
1904
1904
1904
1904
1904
1904
1905
1905
1905
1905
1905
1905
1905
1905
1905
1905
1905
1905
1905
1905
1905
1905
1905
1905
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
ALPHABETICAL LIST OF FELLOWS.
XIX
John Bruce M'Moreland, M.B., Ch.B.,
William Omand Sclater, M.B., Ch.B.,
Archibald George Kirkwood Ledger, M.B., Ch.B., Darwen,
465 Frederick James Greig, L.R.C.P. & S.I., Lt.-Col., R.A.M.C.
Stirling, ......
Duncan Lorimer, M.B., Ch.B.,
Charles Robert Paterson Mitchell, Glasgow, .
William David Osier, .....
John Halley Meikle, M.D., ....
470 David Lloyd Roberts, M.D., F.R.C. P., Manchester, .
James Sutherland Edwards, M.B., Ch.B.,
Alexander Murray Drennan, ....
Mary Caroline Hamilton, L.R.C.P. & S. Ed., L.F.P.S. Glasg
Elsie Mary Macmillan Barnetson, M.B., Ch.B., Joppa,
475 John Andrew Macleod, M.B., Ch.B., Inverness
Hugh Smith Reid, M.D., Ch.B.,
477 Allan Macdonald Dick, M.B., Ch.B., .
Date of
Admission.
1906
1906
1906
1906
1906
1906
1906
1906
1906
1906
1907
1907
1907
1907
1907
1907
ORDINARY FELLOWS.
ARRANGED ALPHABETICALLY.
(a.) LIFE MEMBERS.
Adam, Dr George Roth well, 84 Collins St., Melbourne, Aus.,
Anderson, Dr John, Newholme, Pitlochry,
Ballantyne. Dr Harold S., Ashton, Eskbank, Dalkeith,
Ballantyne, Dr J. W., 24 Melville Street,
5 Barbour, Dr A. H. Freeland, 4 Charlotte Square,
Barclay, Dr William John, Invercargill, New Zealand,
Brock, Dr G. Sandison, 2 Via Veneto, Rome,
Burnet, Dr Edward, 4 Fingal Place, .
Cavanagh, Dr Francis, 396 Ecclesall Road, Sheffield, .
10 Chipman, Dr W. W., 285 Mountain St., Montreal, Canada,
Chouhall, Dr William T., 233 Macquarie St., Sydney,
Australia, ......
Craig, Dr John, 71 Brunts field Place, .
Craig, Dr William, 71 Bruntsfield Place,
Croom, Dr David Halliday, 17 Alva St.,
15 Croom, Prof. Sir John Halliday, 25 Charlotte Square,
Cumming, Dr John, 70 Bruntsfield Place,
Dobell, Dr C. B., 1 Royal Well Terrace, Charlton, Cheltenham
Dumat, Dr Henry Aylmer, 7 Devonshire Place, Durban
Natal, South Africa, ....
Fleming, Dr Andrew M., C.M.G., Salisbury, Rhodesia,
20 Fowler, Dr Simson, Waverley, Juniper Green,
Frost, Dr Edmund, Chesterfield, Meads, Eastbourne, .
Gibson, Dr R. Wilson, Town Head House, Orton, Tebay,
Grant, Dr Lewis, Neston, Cheshire,
Hart, Dr D. Berry, 5 Randolph Cliff, .
25 Inch, Dr Robert, Gorebridge, ....
Johnston, Dr D. W., P.O. Box 2022, Johannesburg, Trans
vaal, ......
Livingston, Dr George R., 47 Castle Street, Dumfries,
1879
1896
1897
1883
1879
1899
1894
1906
1903
1895
1906
1900
1870
1903
1870
1896
1904
1898
1904
1892
1905
1903
1896
1877
1887
1892
1898
XX
ALPHABETICAL LIST OF FELLOWS.
30
55
40
45
M'Arthur, DrW. Taylor, 959 S. Figueroa St., Los Angeles,
California , .
M'Brearty, Dr J. Wilson, Greymouth, West Coast, New
Zealand, .......
M'Farlane, Dr Hilda M., Bendameer, Burntisland,- .
Macnab, Dr James, C. G., The Towers, Dysart,
Maddox, Dr Ralph H., I. M.S., c/o Messrs Thomas Cook &
Son, Ludgate Corner, London, E.C.,
Martin, Dr Christopher, Cleveland House, George Road,
Edgbaston, Birmingham, . . . . .
Melville, Dr Kenmure, 2 Nile Grove, . . .
Morgan, Dr T. H., Gympie, Queensland, Australia, .
Mules, Dr P. Henry, Bishopdale, Nelson, New Zealand,
Pereira, Dr A. A. Jervis, Consul de Grece en Mozambique,
Lourenco. Marques, Delagoa Bay, South Africa, .
Pitts, Dr Edith Cochrane-Brown, Strathmore, Christ Church,
New Zealand, .....
Ponder, Dr Charles F., Glenorchy, Hobart, Tasmania,
Ranking Dr J. E., Tunbridge Wells, .
Ross, Dr James F. W., 481 Sherbourne Street, Toronto, Canada
Russell, Dr J. Lawson, West Lodge, Tormorden,
Simpson, Dr G. F. Barbour, 50 Melville Street,
Simpson, Dr W. Petrie, Viewbank, Bathgate,
Simson, Dr H. J. F., 36 Grosvenor Street, London, W.,
Struthers, Dr John, Nqamakwe, Transkei, South Africa,
Vatve, Dr Gopal Govind, c/o H.H. The Rajah of Miruj
Bombay, India, .....
Wells, Dr A. Simpson, 56 Orange Street, Cape Town, South
Africa, .......
Date of
Admission.
1901
1899
1901
1904
1887
1888
1900
1895
1903
]888
1905
1892
1881
1889
1906
1898
1892
1897
1895
1894
1903
(6.) ANNUAL SUBSCRIBERS.
Aarons, Dr S. Jervois, 14 Stratford Place, London, W., . 1896
50 Adams, Dr Russell G. W., Langley Dale, Blenheim, New
Zealand ....... 1904
Affleck, Dr J. O., 38 Heriot Row, . . . . 1869
Ainslie, Dr A. C, 49 Minto Street, .... 1898
Aitken, Dr C. J. Hill, 19 Church Street, corner of Oxford
Street, East London, South Africa. . . . 1902
Alexander, Dr W. B., 8 Blenheim Place, . . . 1882
55 Allison, Dr J., Fuller House, Kettering, Northampton, . 1888
Anderson, Dr Fred. T., 20 In verleith Row, . . . 1892
Andrew, Dr James, 2 Atholl Crescent, .... 1868
Anklesaria, Dr H. N., 12 Colaba Causeway, Bombay, India, . 1906
Archibald, Dr J., Hazelden, Wimborne Road, Bournemouth, 1877
60 Armitage, Dr J. A., 58 Waterloo Road Wolverhampton, . 1886
Armour, Dr E. F., 6 Bruntsfield Terrace, . . . 1889
Aspland, Dr W. H. Graham, Church of England Mission,
Peking, China, . . . . . . 1901
Baildon, Dr F. J., 42 Hoghton Street, Southport, . . 1887
Baird, Dr W. J., Earls Barton, Northants, . . . 1906
65 Ballantyne, Dr A., Ashton, Eskbank, Dalkeith, . . 1870
Barnardo, Dr F. A. F., Capt. I. M.S., Ferozepore, Punjab,
India, . . . ..... . 1899
Barnetson, Dr Elsie M„ 31 Morton Street, Joppa, ' . . 1907
ALPHABETICAL LIST OF FELLOWS.
XXI
70
75
SO
85
90
95
100
105
1.10
115
120
Barnetson, Dr R. Balfour, 31 Morton Street, Portobello,
Barrington, Dr Fourness, 213 Macquarrie Street, Sydney,
Australia, ......
Barry, Dr W. J. M., 29 Plymouth Road, Penarth, Glamorgan,
Bateman, Dr F. J.Harvey, Heath End, Blackheath, Lond. ,S.E
Beatty, Dr Samuel, Craigvar, Pitlochry,
Beesley, Dr R. W., 135 Deane Road, Bolton, .
Beesly, Dr Lewis, 13 Torphichen Street,
Bell, Dr J. Lumsden, Driffield, Yorkshire,
Bentley, Dr G. H., Loanhead House, Kirkliston,
Beveridge, Dr Robert, 9 James Place, Leith, .
Blaikie, Dr R. H., 10 Mayfield Gardens,
Blair, Dr J. A., 16 Windsor Terrace, Newcastle-on-Tyne,
Blake, Dr R. A., Padn oiler, Sunnyside, Pretoria, South Africa
Bleloch, Dr A., 26 Gilmore Place,
Boddie, Dr G. P., 73 Brimtsfield Place,
Booth, Dr William, 2 Minto Street, .
Borrowman, Dr Philip G., Galvelmore, Crieff,
Boxill, Dr N. L., Buttalls, St George, Barbados,
Brand, Dr Eden, Bellfield, Banchory, .
Brewis, Dr N. T., 6 Drumsheugh Gardens,
Brewis, Dr R. Adams, The West Gate, Dursley, Gloucestershire
Broad, Dr B. W., The Sanitorium, Cardiff,
Brodie, Dr T. Scott, 21 Belhaven Terrace, Wishaw,
Brodie, Dr W. Haig, 6 St Stephen's Road West, West
Ealing, London. W.
Brown, Dr H. Grey, 1 Cluny Avenue, .
Brown, Dr J. Graham, 3 Chester Street,
Brown, Dr William, Braemar, ....
Brownlee, Dr James, 6 Seaton Terrace, Linthrope Road
Middlesbrough, .....
Buist, Dr J. W., 1 Clifton Terrace, .
Buist, Dr R. C, 166 Nethergate, Dundee,
Bunting, Dr W. Hartley, 20 Hagley Road, Edgbaston
Birmingham, .....
Burton, Dr Thomas J., Port Hedland, West Australia,
Butchart, Dr C. A., 52 Leith Walk, Leith,
Cairns, Dr W. Murray, 67 Catherine Street, Liverpool,
Calder, Dr H. L., 60 Leith Walk, Leith,
Callender, Dr D. A., Hazelmere, Toft Road, Knutsford,
Cheshire, .....
Callender, Dr D. M., 6 Rose Bank, Lancaster,
Callender, Dr T. M., Inverard, Sidcup,
Cameron, Prof. James C, M.D., 941 Dorchester Street
Montreal, .....
Campbell, Dr Malcolm, 17 Walker Street,
Carmichael, Dr Edward, 21 Abercromby Place,
Carmichael, Dr E. W. Scott, 32 Rutland Square,
Carmichael, Pr James, 22 Northumberland Street,
Carrnthers, Dr G. J. R., 4 Melville Street,
Cattanach, Dr J. G., 3 Alvanley Terrace,
Church, Dr H. M., 36 George Square, .
Clark, Dr A. W. G., 24 Braid Crescent,
Clark, Dr J. A., 4 Cambridge Street,
Clark, Dr Katherine S., Craigleith Poorhouse,
Cobbett, Dr C. N., Edmonton, Alberta, Canada,
Cox, Dr Joshua J., 38 Deansgate, Manchester,
Craig, Dr R. W., Pathhead-Ford, Dalkeith, .
Oroudace, Dr J. H., Foregate House, Stafford,
Date of
Admission.
1904
1884
1898
1898
1888
1894
1904
1884
1877
1896
1888
1887
1905
1876
1889
1891
1893
1888
1903
1883
1888
1895
1900
1881
1905
1906
1904
1905
1877
1895
1900
1896
1894
1892
1882
1901
1902
1896
1888
1900
1887
1899
1871
1901
1893
1875
1901
1887
1903
1890
1876
1905
1878
XX11
ALPHABETICAL LIST OF FELLOWS.
125
130
135
140
145
150
155
160
165
170
Cullen, DrG. M., 50 Minto Street, .
Cunningham, Dr Barbara M., Dufferin Hospital, Nagpur
Central Provinces, India, .
Currie, Dr A. S., 20 Oxford Terrace, Hyde Park, London, W.
Dadabhoy, Dr K., Karachi, India,
Darling, Dr T. Brown, 1 3 Merchiston Place, .
Darling, Dr William, 2 Warrender Park Terrace,
Davidson, Dr D. G., 9 Granville Terrace,
Davidson, Dr H. S., 4 Dundas Street, .
Davidson, Dr Samuel, Kelso, ....
Davies, Dr Arnold, Grammar School, Menai Bridge, North
Wales, ......
Davies, Dr E. T. , 1 St Domingo Grove, Liverpool,
Dendle, Dr Frank, Overton House, Spring Grove, Isleworth,
Deverell, Dr H. C, 12 Windsor Street,
Dewar, Dr M., 24 Lauriston Place,
Dick, Dr A. Iff., Edinburgh University Union,
Dickie, Dr J. T., 37 Lauriston Place, .
Dickson, Dr George, 9 India Street,
Dickson, Dr George, 14 Ardmillan Terrace,
Dobie, Dr D. Robertson, Heathfield, Crieff,
Donald, Dr C. W., 28 Portland Square, Carlisle,
Drennan, Dr A. Murray, 36 Woodburn Terrace,
Dunbar, Dr H. J., 1 Kew Terrace,
Duncan, Dr A. J., 158 Nethergate, Dundee, .
Duncan, Dr A. S., .....
Dunlop, Dr H. M., 20 Abercromby Place,
Dyer, Dr E, W., c/o Messrs Webster, Steel & Co., 5 East
India Avenue, Leadenhall Street, London, E.C., .
Eason, Dr John, 58 Northumberland Street, .
Easterbrook, Dr A. M., Am prior, Gorebridge,
Easterbrook, Dr C. C, Glengall, Ayr, .
Easton, Dr Thomas, 23 East Park Terrace, Southampton,
Eden, Dr T. Watts, 26 Queen Anne Street, Cavendish Squar
London, W. , . .
Edington, Dr D. C, 4 Portland Place, Penrith,
Edwards, Dr J. S., University Union,
Elder, Dr Edward A., 6 Torphichen Street,
Elder, Dr Eleanor, 4 John's Place, Leith,
Elder, Dr W. Nicol, 6 Torphichen Street,
Evans, Dr O. F., 20 Princes Avenue, Liverpool,
Farie, Dr G. J., Strathallan House, Bridge of Allan
Farquharson, Dr J. D., 242 Westgate Road, Newcastle-on
Tyne, ......
Faulkner, Dr Hugh, St John's House, Banbury, Oxon
Felkin, Dr R. W., 12 Oxford Gardens, North Kensington
London, W., ....
Ferguson, Dr J. Haig, 7 Coates Crescent,
Ferguson, Dr P. J. H. , 9 Windsor Street,
Ferguson, Dr R. T., Middlemarch, Anstruther, Fife, .
Finlay, Dr W. A., 50 Trinity Road, .
Fitzwilliams, Dr D. C. L., 64 Brook Street, Grosvenor Square
London, W., .....
Fleming, Dr Andrew, St John's Road, Corstorphine, .
Flett, Dr A. B., 60 George Square,
Forbes, Dr J. Christie, Ardv* ich, Liberton,
Fordyce, Dr A. Dingwall, 19 Coates Crescent,
Fordyce, Dr William, 20 Charlotte Square,
Fothergill, Dr W. Edward., 13 St John Street, Manchester,
Date of
Admission.
1890
1906
1882
1906
1884
1900
1892
1904
1906
1906
1887
1892
1882
1891
1907
1900
1867
1901
1894
1895
1907
1905
1879
1890
1884
1906
1899
1893
1892
1894
1888
1897
1906
1906
1903
1879
1890
1903
1890
1902
1884
1885
1900
1895
1880
1904
1905
1903
1898
1899
1888
1894
ALPHABETICAL LIST OF FELLOWS.
XX111
Forrester, Dr C. C, 3 Albert Terrace, .
Fowler, Dr W. Hope, 5 St Vincent Street,
175 Fox, Dr J. W., 18 Bernard Street, Southampton,
Fraser, Dr J. Hossack, Fernfield, Bridge of Allan,
Fraser, Dr Nutting S., 205 Gower Street, St John's, New
foundland, ......
Frost, Dr W. E., 6 Atholl Place,
Garbutt, Dr W. J., 1 Bournbrook Rd., Selly Pk., Birmingham
180 Gardiner, Dr Frederick, 9 George Square,
Gavin, Dr Alfred T., Doonlea, Dunaskin,
Gayton, Dr William, Ravensworth, Regent's Park Road
Finchley, London, N.,
Gemmell, Dr J. E., 28 Rodney Street, Liverpool,
Gibbons, Dr Sherwin, 1013 Braly Building, Los Angeles,
California, ......
185 Gibbs, Dr J. H., 7 Coates Place,
Gibson, Dr Cameron R., 101 Forest Road, Nottingham,
Giffen, Dr J. T. M., 138 Boughton, Chester, .
Giles, Dr A. B., 4 Palmerston Place, .
Gilmour, Dr T. F., Port Ellen, Islay, .
190 Glegg, Dr R. Ashleigh, Public Health Office, Leith, .
Godfrey, Dr W. F., 46 Cumberland Street
Gordon, Dr Henry F., 178 Colony Street, Winnipeg, Canada.
Graham, Dr A., Curriebank, Currie,
Graham, Dr D. J., 26 Rutland Street, .
195 Graham, Dr F. M., 16 Mayfield Gardens,
Graham, Dr J. Gibson, 17 Ashton Ter., Dowanhill, Glasgow
Graham, Dr R. Balfour, Leven, Fife, .
Green, Dr John Ligertwood, 23 Minto Street, .
Greene, Dr T. W. N., 45 Dartmouth Square, Leeson Park
Dublin, .......
200 Gregory, Dr W. H., North Bar Street, Beverley, Yorks,
Greig, Dr F. J., Lt.-Col. R.A.M.C., 16 Melville Ter., Stirling,
Gunn, Dr . J. A., Materia Medica Department, University of
Edinburgh, ....
Guthrie, Dr A. Cowan, 21 Pilrig Street,
Hall, Dr A. A., 8 Vanburgh Place, Leith,
205 Hall, Dr D. G., 30 Brunswick Place, Hove, Brighton
Hamilton, Dr J. R., Elm House, Hawick,
Hamilton, Dr Mary, Pengarth, St Agnes, Cornwall,
Hamp, Dr J. Walton, Penn Road, Wolverhampton,
Hardie, Dr Mabel, High Lane, near Stockport,
210 Harley, Dr R. J., ....
Harlin, Dr Francis W., Peak Downs District Hospital
Clermont, Queensland, ....
Harper, Dr R. A. J., Abbey Road, Barrow-in-Furness
Harvey, Dr Charles E., Kingswood, Sav-la-Mar, Jamaica
W.I., ....
Harvey, Dr James, 7 Blenheim Place, .
215 Haultain, Dr F. W. N., 12 Charlotte Square,
Havelock, Dr J. G., Sunnyside, Montrose,
Hay, Dr Henry, 11 Great King Street,
Hellier, Dr J. B., Glengariff, North Grange Road, Headingley
Leeds, .....
Helm, Dr J. H. , Clarence Cottage, Ratho,
220 Helm, Dr R. Dundas, 13 Portland Square, Carlisle,
Helme, Dr G. Edgar, Gloucester House, Rusholme, Manchester
Henderson, Dr Alexander, 21 Pitt Street
Hewetson, Dr J., Holmfield
Date of
Admission.
1898
1900
1887
1895
1887
1900
1897
1900
1905
1885
1885
1904
1905
1903
1892
1891
1882
J901
1906
1906
1897
1895
1894
1888
1893
1902
1889
1893
1906
1906
1888
1905
1900
1879
1907
1886
1902
1905
1900
1901
1889
1891
1884
1888
1879
1904
1888
1892
1895
1891
1881
XXIV
ALPHABETICAL LIST OF FELLOWS.
Hindmarsh, Dr Edwin, Mozufferpore, Tirhoot State Railway
Bengal, India, .....
225 Hobson, Dr H. Overton, Villa Sakkara, Helouan, Egypt
Hoggan, Dr Robert, Liberton Park, Liberton, .
Holmested, Dr C. W., Tuxford, Newark, Notts,
Hughes, Dr H. L., Llwyn-Werm, Dowlais, Glamorganshire,
Hughes, Dr P. T., County Asylum, Broomsgrove, Worcester
shire, .... .
230 Hunter, Dr George, 33 Palmerston Place,
Hutcheson, Dr J. , 44 Moray Place,
Hutchison, Dr Alice M., 204 Bruntsfield Place,
Inglis, Dr Elsie M., 8 Walker Street, .
Jamieson, Dr Hugh, 1 Strathearn Road,
235 Jamieson, Dr J. Boyd, 43 George Square,
Jardine, Dr Robert, 20 Royal Crescent, Glasgow, W.,
Jeffrey, Dr John, Glen Bank, Jedburgh,
Johnston, Dr Robert B., Bishopyards, Penrith,
Johnston, Dr R. J., 1 Buccleuch Place,
240 Johnstone, Dr R. W., 13 Torphichen Street, .
Jones, Dr W. Llewellyn, 58 Thomas St., Merthyr-Tydvil,
Keay, Dr J. W., 12 Brougham Place, .
Keiller, Prof. Wm., 210 Levy Building, Galveston, Texas
U.S.A
Keir, Dr Ian C, The Limes, Melksham, Wilts,
245 Ker, Dr Claude B., City Hospital, Comiston Road,
Kerr, Dr J. M. Munro, 7 Clairmont Gardens, Glasgow,
Kerr, Dr J. Wishart, 107 Greenhead Street, Glasgow,
King, Dr J. K., The Glen Springs Sanitorium, Watkins
New York, U.S.A., .....
Kirk, Dr Robert, Rowan Bank, Bathgate,
250 Kirkness, Dr J. M., 14 Dalkeith Road,
Kynoch, Professor Campbell, 8 Airlie Place, Dundee, .
Lackie, Dr James, 1 Randolph Crescent,
Laing, Dr J. H. A., 11 Melville Street,
Langwell, Dr H. G., 4 Hermitage Place, Leith,
255 Leary, DrT. Garnet S., Grand Hotel, Melbourne, Australia,
Ledger, Dr A. G. K., 97 Blackburn Road, Darwen, .
Lee, Dr Herbert E., Gunnedah, N.S.W., Australia,
Lewis, Dr Arthur J., c/o R Shaw, Esq., 36 Woodburn Terrace
Littlejohn, Professor Harvey, 11 Rutland Street,
260 Lochhead, Dr James, Earlston,
Lockhart, Dr F. A. L., 23 Mackay Street, Montreal, Canada,
Lorimer, Dr Duncan, 74 Bruntsfield Place,
Low, Dr R. Cranston, 6 Castle Terrace, . .
Lvell, Dr John, 15 Marshall Place, Perth,
265 Lyle, Dr F. W., 97 Gordon Road, Ealing, London, W., '
Lyle, Dr R. P. Ranken, 11 Ellison Place, Newcastle-on-Tyne
Mac Arthur, Dr D. G., Aberfeldy,
M'Call, Dr John, 25b Abercromby Terrace, Portobello,
M'Callum, Dr H., Kinloch-Rannoch, .
270 M'Cann, Dr F. J., 5 Curzon Street, Mayfair, London, W..
Macdonald, Dr Alexander, 42 Polwarth Terrace,
Macdonald, Dr A. G., 11 Manor Place,
Macdonald, Dr Angus, 27 Manor Place,
Macdonald, Dr John, Marathon House, Cupar-Fife, .
275 Macdonald, Dr W. Fraser, 16 Buckingham Ter., Glasgow, AY
M'Ewan, Dr Peter, Royal Infirmary, Bradford, Yorks,
M'Gibbon, Dr John, 22 Heriot Row, .
MacGregor, Dr Alastair, Stafford Lodge, Market Harborough
Date of
Admission.
1895
1901
1894
1900
1894
1895
1881
1888
1905
1901
1889
1900
1897
1901
1903
1899
1903
1903
1903
1890
1903
1894
1894
1901
1884
1887
1903
1892
1889
1891
1891
1904
1906
1892
1906
1890
1904
1890
1906
1902
1901
1890
1901
1903
1886
1887
1896
1898
1903
1897
1902
1884
19d5
1902
1905
ALPHABETICAL LIST OF FELLOWS.
XXV
280
285
290
295
300
SOf
310
315
320
126
330
MacGregor, Dr A. V., Durham House, West Hartlepool,
MacGregor, Dr Donald, Seaton House, Jedburgh,
Macgregor, Dr G. S., 2 Burnbank Terrace, Glasgow W.,
M'llwraith, Dr Kennedy C, 54 Avenue Rd., Toronto, Canada
Mackay, Dr George, 74 Bruntsfield Place,
Mackay, Dr W. B., 23 Castlegate, Berwick-on-Tweed,
M'Kendrick, Dr Archd., 120 High St., Kirkcaldy,
Mackenzie, Dr R., Napier, Nairn,
Mackenzie, Dr T. C, Aberdeen Royal Asylum,
M'Kerron, Dr R. Gordon, 1 Albyn Place, Aberdeen, .
Mackie, Dr George, Boyd's Lodge, Malvern, Worcestershire,
Mackin, Dr Patrick, 12 Ingestre St., Wellington, New Zealand,
Mackness, Dr G. O. C., Fort Street House, Broughty-Ferry
Maclagan, Dr D. W., Kaponga, Taranaki, New Zealand,
M'Larty, Dr Malcolm, 7 Bellevue Place,
M'Lean, Dr Archibald, Crosshouse, Kilmarnock,
Maclean, Dr Ewen, J., 12 Park Place, Cardiff,
Macleod, Dr J. A., The Asylum, Inverness,
M 'Master, Dr A. C, Australasian Club, Melbourne Place,
Macmillan, Dr John, 48 George Square,
M'Morland, Dr J. B., 19 Merchiston Gardens,
MacRae, Dr John, Lynwood, Murray field,
Mac Vie, Dr S. , Chirnside, ....
M'Watt, Dr John, Duns, ....
Macwatt, Dr R. C, 7th Bengal Cavalry, c/o Messrs King,
King & Co., Bombay, India,
Malcolmson, Dr Alexander M., Dalveen, St John's Road
Corstorphine, .....
Maloney, Dr W. J., Kasr-El. Aing. Hospital, Cairo, .
Manford, Dr J. Stanley, 1 Osborne Terrace, Newcastle-on
Tyne, .......
Marshall, Dr G. Balfour, 19 Sandyford Place, Glasgow,
Marshall, Dr William, Milnathort,
Martin, Dr Angus, 25 Northumberland Square, North Shields
Martin, Dr Charles, Dagenham House, Newton Abbot, South
Devon, ......
Martin, Dr J. W., Charterhall, Newbridge, Dumfries,
Matheson, Dr A. A., 41 George Square,
Matheson, Dr Roderick M., 33 Buccleuch Place,
Mathewson, Dr G. P., 25 Cluny Gardens,
Maurange, Dr Gabriel, 6 Rue de Tournon, Paris,
Meikle, Dr J. Hally, 12 Midmar Gardens,
Menzies, Dr David, 20 Rutland Square,
Messer, Dr Fordyce, Woodlands, Garelochhead,
Michael, DrGustave, 5 Cambridge Place, Chestergate, Regent
Park, London, N.W.,
Millard, Dr W. W., Middlefield House, Leith Walk, .
Miller, Dr Alexander, 1 Royal Terrace, Crossbill, Glasgow,
Miller, Dr W. H., 51 Northumberland Street, .
Milne, Dr W. M., 10 Newington Road,
Mitchell, Dr C. R. P., 1 Bowmont Gardens, Glasgow,
Mitchell, Dr G. B., 1 Skinner Street, Whitby,
Mitchell, Dr R. M., Government Hospital, Coolgardie
Western Australia, .....
Montgomery, Dr John, The Highlands, Balsall Heath
Birmingham, .....
Moorhouse, Dr J. Ernest, 6 Melville Terrace Stirling,
More, Dr James, Rothwell, Kettering, Northampton, .
Morison, Dr Albert E., Wellington Road, West Hartlepool,
Date of
Admission.
1895
1900
1888
1901
1879
1899
1906
1887
1900
1896
1900
1895
1887
1901
1900
1890
1902
1907
1906
1897
1906
1893
1881
1879
1885
1901
1905
1900
1891
1884
1906
1892
1887
1887
1897
1905
1898
1906
1877
1866
1885
1884
1902
1886
1898
1906
1893
1900
1895
1892
1880
1888
62
XXVI
ALPHABETICAL LIST OF FELLOWS.
Morris, Dr S. Glanville, Brynawel, Mardy, Glamorganshire
Moses, Dr 0. St John, 8 Lansdovvne Road, Calcutta, .
Mowat, Dr John, 5 Hope Park Terrace,
Munro, Dr J. Ramsay, Sutter ton, Boston,
335 Murray, Dr A. Lang, Killara, Sydney, N.S.W., Australia,
Murray, Dr D. R., 41 Albany Street, Leith,
Murray, Dr James, 1 Brandon Street, .
Napier, Dr A. D. Leith, 28 Angas Street, Adelaide, South
Australia, ......
Nicholson, Dr H. Oliphant, 20 Manor Place, .
340 Ogdcn, Dr 0 Watson, 38 Jesmond Road, Newcastle-on-Tyne
Ogilvy, Dr Stewart Grant, Fairmont, Fauldhouse,
Oliphant, Dr E. H. Lawrence, 23 Newton Place, Glasgow,
Orr, Dr John, Heather Lea, Clarendon Road, Eccles, Lanes.,
Orr, Dr W. Basil, 13 Braid Road,
345 Osier, Dr W. D., 11 Montgomery Street,
Paterson, Dr G. Keppie, 19 Albany Street,
Paterson, Dr G. W. Simla, 147 Kruntsfield Place,
Patton, Dr W. Scott, Capt., I. M.S., " Scotts Burn," Landour
Mussoorie, N.W.P., India,
Pearson, Dr C. M., 14 Manor Place, .
350 Peddie, Dr H. Anderson, 24 Palmerston Place,
Perigal, Dr A., New Barnet, Herts,
Pirie, Dr John, 15 Ardmillan Terrace,
Playfair, Dr John, 5 Melville Crescent,
Poole, Dr T. D., North Side House, Linthwaite, near
Huddersfield, .....
355 Porritt, Dr E. E., Wanganui, New Zealand, .
Porteous, Dr J. Lindsay, 83 Warburton Avenue, Yonkei
New York, ......
Porter, Dr Frederick, 65 Morningside Road,
Potts, Dr W. A., 118 Hagley Road, Edgbaston, Birmingham,
Prentice, Dr W. H., Brunswick - Terrace, Brood Street,
Pendleton, Manchester, .
360 Price, Dr A. W. Gordon, 9 Grange Road,
Price, Dr E. F. T.. 1 Middleby Street,
Primrose, Dr Alex., 100 College Street, Toronto, Canada,
Pringle, Dr J. Hogarth, 172 Bath Street, Glasgow, .
Proudfoot, Dr Thomas, 30 Lauriston Place,
365 Rabagliati, Dr A. H., 1 St Paul's Road, Bradford, Yorkshire,
Randell, Dr H. St John, Aliwal North, Cape Colony,
Reid, Dr H. S., 5 Ravelston Park, . .
Reid, Dr W. L., 7 Royal Crescent W., Glasgow,
Rendell, Dr Herbert R., P.O. Box 606, St John's, New-
foundland, . . . . . . • .
370 Rhodes, Dr J. H., Vicarage Terrace, Kendal, .
Ritchie, Dr James, 22 Charlotte Square,
Ritchie, Dr W. T., 9 Atholl Place, . . . .
Robarts, Dr Henry H., Wemyss Place, Haddington, .
Roberton, Dr Ernest, Cotele House, Symond Street, Auck-
land, New Zealand, .
375 Roberts, Dr D. Lloyd, 11 St John Street, Manchester,
Roberts, Dr Ernest T., Oaklands House, Keighley,
Roberts, Dr R. W. , Grove Place, Port Talbot, Glamorganshire,
Robertson, Dr George, Braehrad, Viewfield Place, Dunfermline,
Robertson, Dr Robert, 26 Royal Circus,
380 Robertson, Dr W. B., St Anne's, 101 Thurlow Park Road,
West Dulwich, London, S.E., . . . .
Robertson, Dr W. G. Aitchison, 26 Minto Street,
Date of
Admission.
1894
1900
1884
1901
1889
1878
1879
1878
1900
1900
1895
1885
1887
1889
1906
1882
1896
1901
1902
1882
1887
1888
1873
1890
1897
1875
1904
1897
1901
1890
1890
1887
1886
1884
1903
1906
1907
1880
1882
1898
1880
1899
1904
1887
1906
1890
1894
1901
1897
1870
1889
ALPHABETICAL LIST OF FELLOWS.
XXV11
385
390
395
400
405
410
415
420
425
430
Robins, Dr H., Sav-la-Mar, Jamaica, W.I.,
Robinson, Dr H. Shapter, Talfourd House, 78 Peckham Road
Camberwell, London, S.E.,
Ronaldson, Dr T. R., 8 Charlotte Square,
Rosa, Dr Albert F., 28 Pitt Street,
Ross, Dr J. W. E., 1 Clare Street, Cardiff,
Russell, Dr W., 3 Walker Street,
Saleeby, Dr C. W., 13 Greville Place, London, N.W.
Sandstein, Dr Alfred C, 23 Latimer Square, Christchureh
New Zealand, .
Saunders, Dr F. A., Grahamstown, Cape Colony, South
Africa, ......
Schofield, Dr Linn J., Warrensburg, Mo., U.S.A.,
Sclater, Dr W. O., 16 War render Park Crescent,
Scott, Dr Alexander, The Firs, Broxburn,
Scott, Dr T. R., Musselburgh, ....
Secord, Dr E. R., 112 Market St., Brantford, Ontario, Canada
Shaw, Dr C. J., Royal Lunatic Asylum, Montrose,
Shaw, Dr W. J., Cockburnspath,
Shearer, Dr Alfred, Newtown, N. Wales,
Simpson, Dr Archibald, The Hospital, Darlington,
Simpson, Dr F. D., 7 Kew Terrace,
Slight, Dr J. D., 61 London Road, Leicester,
Sloan, Dr Allen T., 22 Ahercromby Place,
Sloan, Dr S., 5 Somerset PI., Sauchiehall St. West, Glasgow,
Sloss, Dr William, Windsor, Sturt Street, Ballarat, Mel
bourne, Australia, ....
Smart, Dr David, 74 Hartington Rd., Sefton Park, Liverpool,
Smith, Dr G. H. Walton, Pendower, Oxford St., Paddington,
Sydney* Australia, ......
Smith, Dr Gains T., 15 Church Street, Moncton, New Brunswick,
.Canada, ......
Smith, Dr James, 4 Brunton Place,
Smith, Dr John, Hrycehall, Kirkcaldy,
Smith, Dr W. Ramsay, Winchester St., East Adelaide, Aus
Smith, Dr W. Torrance, Linwood, Midcalder,
Sneddon, Dr William, 58 Bonnygate, Cupar-Fife,
Somerville, Dr C. W., London Mission, Wuchang, by Hankow
Central China, .....
Somerville, Dr James W., 12 Abbotsford Road, Galashiels,
Spalding, Dr William, Gorebridge,
Spence, Dr R., St Ninians, Burntisland,
Spence, Dr William. Sydney House, Dollar,
Stephen, Dr W. A., Loftus-in-Cleveland, Yorkshire, .
Stevens, Dr John, 78 Polwarth Terrace,
Stewart, Dr A. D., 8 Brougham Place,
Stewart, Dr J. S.. 15 Merchiston Place,
Stewart, Dr R., 25 George Square,
Stirling, Dr R,, 4 Atholl Place, Perth,
Story, Dr B. S. , Wellington, New Zealand, .
Strain, Dr Arthur C. , Grange House, West Hartlepool,
Stumbles, Dr H. M., Amble House, Amble, Northumberland
Sturrock, Dr J. F., Arima, Bronghty-Ferry, .
Sullivan, Dr John, 34 Gilmore Place, .
Taylor, Dr David R., St Helen's, Ayton,
Taylor, Dr William, 12 Melville Street,
Taylor, Dr W. Macrae, 12 Melville Street,
Teacher, Dr C, Ciaieend, North Berwick,
Temple, Dr G. H., Ailanthus, Weston-super-Mare,
Date of
Admission.
1893
1890
1877
1893
1904
1890
1902
1898
1885
1893
1906
1906
1880
1902
1903
1892
1898
1906
1900
1898
1893
1887
1902
1882
1892
1891
1891
1885
1892
1906
1888
1902
1902
1867
1878
1884
1894
1894
1906
1884
1885
1892
1898
1904
1903
1887
1902
1896
1868
1895
1887
1888
XXVlll
ALPHABETICAL LIST OF FELLOWS.
435
440
445
450
455
460
465
470
475
477
Tennant, Dr John, Scunthorpe, near Doncaster,
Thatcher, Dr C. H., 8 Melville Crescent,
Thin, Dr Robert, 25 Abercromby Place,
Thomas, Dr G. Crewdson, 34 West Hill, Sydenham, London
S.E., ......
Thompson, Dr F. E., 20 Park Avenue, Montreal, Canada,
Thompson, Dr Herbert P., c/o Mackay, 52 Morningside Road
Thompson, Dr James L., Castlemaine, Victoria, Australia,
Thompson, Dr John A. Douglas, Comberton House, Hale-
sowen, Worcestershire, ....
Thomson, Dr A. D. R., 19 Bridge Street, Musselburgh,
Thomson, Dr John, 14 Coates Crescent,
Thomson, Dr J. Stitt, Castle Hill House, Lincoln,
Thomson, Lr T. J., 31 Morningside Road,
Thyne, Dr T. J., 16 Randolph Crescent,
Tod, Dr John, 69 Ferry Road, Leith, .
Tough, Dr F. W. K., 24 Junction Lane, St Helen's Junction
Lancashire, .....
Tristan, Dr R. J. , 28 Carolgate Retford, Notts,
Underhill, Dr C. E., 8 Coates Crescent,
Underhill, Dr T. Edgar, Dunedin, Barnt Green, Worcestershire
Vassie, Dr Alexander H., 98 Priory Road, West Hampstead.
London, N.W., .
Vickery, Dr W. H., 1 Trewartha Park, Weston-super-Mare,
Wade, Dr George, St John's, Melrose, .
Walker, Dr Arthur S., Ashleigh, Middlesborough,
Wallace, Dr Abraham, 39 Harley Street, London, W. ,
Wallace, Dr R. W. L. , The Royal Boscombe and West Hants
Hospital, Bournemouth, ....
Watson, Dr B. P., 6 Castle Terrace, .
Watson, Dr R. H. , Rousden, Park Road, Hamilton, .
Waugh, Dr John, 36 Finsbury Pavement, London, E. C. ,
Webster, Dr A. D., 18 Minto Street, .
Webster, Prof. J. C, 706 Reliance Building, 100 State Street
Chicago, U.S.A.,
White, Dr A. L., Tantallon, Manchester Road, Castleton
Manchester, .....
Wilcockson, Dr G. Morton, Whitley Cross, Reading, .
Wilkie, Dr James, Selville House, Portobello, .
Wilkinson, Dr George, 3 Dingle Hill, Liverpool, S., .
Will, Dr J. C. Ogilvie, 17 Bon-Accord Square, Aberdeen,
Williams, Dr J. T., Bronygar, Treharris, Glamorgan
shire, ......
Willcox, Dr F. Mayes, 8 Strathearn Road,
Wilson, Dr James, 53 Inverleith Row, .
Wise, Dr Robert, 290 Ivy dale Road, Nunhead, London, S.E.
Wood, Dr Thomas, 182 Ferry Road, .
Woodside, Dr J. T. , Stewartstown, Co. Tyrone,
Wright, DrW.F., . , .
Yoe, Dr Richard T., 2103 Floyd Street, Louisville, Kentucky
U.S. A
Young, Dr H. C. Taylor, 209 Macquarrie Street, Sydney, New
South Wales, .....
Young, Dr Peter A., 25 Manor Place, .
Date of
Admission.
1902
1877
1891
1899
1902
1906
1894
1902
1877
1887
1877
1902
1887
1892
1901
1887
1872
1879
1891
1892
1893
1906
1879
1905
1902
1896
1881
1881
1889
1903
1893
1897
1889
1867
1904
1902
1889
1890
1886
1898
1887
1891
1900
1871
CONTENTS
I.— COMMUNICATIONS RELATING TO OBSTETRICS.
PAGE
Inaugural Address on the Future of Obstetrics. By J. W.
Ballantyne, M.D., F.R.C.P.E., F.K.S.E. ... 3
The Management of Some Difficult Occipito-Posterior Cases. By
J. Lamond Lackie, M.D., F.R.C.P.(Ed.) ... 28
On the Prognosis of Pregnancy in Patients with one Kidney, with
Notes of an Unusually Complicated Case of Labour after
Nephrectomy. By James Haig Ferguson, M.D., F.R.C.P.E.,
F.R.C.S.E., F.R.S.E . 57
Successful Treatment of Puerperal Fever by Antistreptococcic
Serum. By Dr Garnet Leary ..... 67
Exophthalmic Goitre in its Relation to Obstetrics and Gynaecology.
By Professor Sir Halliday Croom, M.D., F.R.C.P.E.,
F.R.C.S.E 143
Epilepsy and the Status Epilepticus in connection with Pregnancy
and Labour, with Illustrative Cases. By Professor Robert
Jardine, M.D. (Ed.), F.F.P.S. (Glas.) . . . .165
A Series of Five Cases of Cesarean Section for Contracted Pelvis.
By Professor John A. C. Kynoch, M.B., F.R.C.P.,
F.R.C.S. (Ed.) 221
II.— COMMUNICATIONS RELATING TO GYNECOLOGY.
Two Cases of Pregnancy complicated by Fibroid Tumours, treated
by Hysterectomy. By N. T. Brewis, M.B., F.R.C.P.E.,
F.R.C.S.E 49
XXX CONTENTS.
PAGE
Case of Acute Albuminuria, caused by the Pressure of a Tumour on
both Ureters — Operation — Recovery. By Frederick Porter,
M.B., CM. 75
Intractable Uterine Haemorrhage, and Arterio- Sclerosis of the
Uterine Vessels. By Elizabeth H. B. Macdonald, M.A.,
M.D., Ch.B 83
A Clinical and Anatomical Study of Thirty Cervical Fibroids
removed by Abdominal Hysterectomy. By F. W. N.
Haultain, M.D., F.R.C.P. (Ed.) 121
Hysterectomy for Fibroid Tumours in Pregnancy. Two Cases.
By A. H. F. Barbour, M.D., F.R.C.P.E. . . .136
Bilateral Ovarian Dermoid Tumours, complicating Pregnancy. By
Malcolm Campbell, M.A., M.B., B.Ch., F.R.C.S.E. . .184
Six Cases of Vaginal Cesarean Section. By N. T. Brewis, M.B.,
F.R.C.P.E., F.R.C.S.E 191
III.— MISCELLANEOUS COMMUNICATIONS.
A Case of Repeated Abortion due to Syphilis ; Treatment by
Potassium Iodide. Birth of Child with Congenital Goitre.
By B. P. Watson, M.D., F.R.C.S.E 204
The " Byrth of Mankynde." (Its Contents.) By J. W. Ballantyne,
M.D., F.R.C.P.(Edin.), F.R.S. (Edin.) . . . .236
TABLE SHOWING SPECIMENS EXHIBITED
AT MEETINGS.
I.—OBSTETRICAL AND TERATOLOGICAL.
PAGE
Foetus (extra-uterine), four months', removed by vaginal section ;
and a portion of the placenta (Dr Brewis) . . . 140
Foetus, frozen sections of, showing hidden cervical spina bifida (Dr
J. W. Ballantyne) . . . . . . .121
Kidneys, pair of cystic (adenomatous), from a still-born foetus
(Dr J. W. Ballantyne) . . . . . .120
Ovum, specimen of an early (Dr James Ritchie) . . . 48
Pelvis (justo-minor, with rickets), from primipara who died in
eclamptic coma (Dr Haig Ferguson) . . . .142
Specimen, analogous to "Foetus Ovideus," obtained from a
multipara (Dr Haultain) ...... 48
II.— GYNECOLOGICAL.
A. AFFECTIONS OF UTERUS.
(1) Fibkoid Tumours—
(a) Simple —
Fibroid, soft subperitoneal, resembling ovarian cyst,
removed by abdominal hysterectomy (Dr Haig
Ferguson) ...... 47
Fibroid, multiple, giving rise to retention of urine (Dr
Haultain) ...... 75
Fibroid, cervical, growing from anterior wall of cervix and
removed by pan-hysterectomy (Dr Brewis) . . 141
Pelvic Abdominal Tumour, consisting of — (1) large sub-
mucous fibroid j (2) fibroid between the layers of right
broad ligament and united with the submucous
fibroid (Dr Haig Ferguson) . , . .142
xxxi
XXX11 TABLE OF SPECIMENS.
(1) Fibroid Tumours — continued,
(a) Simple — continued.
Fibroid, cervical (Dr Fordyce) . . . . 1 04
VA. Jfr.
Fibroids, multiple, removed for pressure symptoms (Dr
Fordyce) . . . . . . |f>4
Fibroids, multiple, removed for post-climacteric haemor-
rhage (Dr Fordyce) . . . . 1 64
Uterus containing a large Submucous Fibroid attached by
broad pedicle to fundus (Dr Brewis) . . . 190
Fibroid, large soft oedematous, removed by hysterectomy
(Dr Brewis) . . . . . .190
Fibroid, cervical, weighing 12 lbs., causing retention of
urine; removed by supravaginal hysterectomy
(Professor Kynoch) ..... 220
Mucous Polypus and Adenomatous Growth associated
with Fibroid Uterus (3 specimens), (Dr Haultain) . 75
Fibroids complicating Pregnancy —
Uterus with large Cervical Fibroid, removed at the fifth
month of pregnancy j Caesarean section and hyster-
ectomy (Dr Brewis) . . . . . 44
Uterus with Fibroid Tumour in lower uterine segment,
removed at term by supravaginal hysterectomy after
Caesarean section (colloid degeneration of the
fibroid), (Dr Brewis) ..... 45
Uterine Fibroid, complicated with pregnancy at fourth
month, removed by hysterectomy (Professor Kynoch) 220
(b) Degenerated —
Fibroid, large subperitoneal, showing mucoid degeneration,
with a very small pedicle (Dr Brewis) . . . 141
Fibroid, interstitial, showing necrobiosis (Dr Fordyce) . 164
(c) With malignancy —
Uterus showing combined Fibroid Tumour and Carcinoma
(Dr Fordyce) 164
TABLE OF SPECIMENS. XXxiil
(2) Malignant Disease of Uterus —
PAGE
Uterus with Fundal Carcinoma, removed by vaginal hyster-
ectomy from multipara eet. 55 (Dr Haig Ferguson) . 46
Chorion Epithelioma of Uterus, removed by vaginal hyster-
ectomy from patient set. 38 (Dr Haig Ferguson) . . 46
Sarcomatous Uterus, round-celled, which filled entire cavity,
perforated the wall, and involved the peritoneal cavity j
abdominal section (Dr Haultain) .... 74
Uterus with Adeno-carcinoma of body, removed per vaginam
from multipara aet. 42 (Dr Haig Ferguson) . . 163
Carcinoma of Uterus (3 specimens — 2 cervical, 1 corporeal),
removed by vaginal hysterectomy (Dr Fordyce) . . 1 64
Uterus with Adeno-carcinoma of the body, removed by vaginal
hysterectomy from multipara set. 44 (Dr Haig Ferguson) 191
(3) Other Uterine Conditions—
Inverted Uterus of puerperal origin, removed by vaginal
hysterectomy (Dr Haig Ferguson) .... 46
Uterus (transformed into abscess cavity), removed by vaginal
hysterectomy one year after double pyosalpinx had been
removed by abdominal section (Dr Haig Ferguson) . 47
Specimen of Diffuse Uterine Fibrosis (Dr Haultain) . . 74
Uterus removed by abdominal hysterectomy for perforating
abscess of its wall, arising from septicaemia after abortion
(Dr Haultain) ...... 74
Specimen showing Tubercular Endometritis (Dr Haultain) . 164
Uterus removed by vaginal hysterectomy for bleeding (and,
from same patient, a Haematoma of left broad ligament)
(DrBrewis) ....... 190
B. AFFECTIONS OF THE OVARIES.
Fibrous Tumour of Ovary, which had been wedged in pelvis,
simulating uterine tumour ; abdominal section (Dr Barbour) . 121
Iluptured Ovarian Cyst, with pseudo-myxoma peritonei (Dr
Barbour) ........ 121
Ovarian Tumour (cyst), removed by abdominal section from a
patient who had been operated on by Thomas Keith nineteen
years before (Dr Brewis) . . . . . . 141
TEANS ACTIONS
EDINBURGH OBSTETRICAL SOCIETY,
FOE SESSION LXVIIL, 1906-1907.
Meeting I.— November 14, 1906.
Dr J. W. Ballantyne, President, in the Chair.
I. The Treasurer {Dr Wm. Craig) made his Annual State-
ment, which is given below : —
INCOME.
Balance from Session 1904-1905,
Arrears, . . . .
Bank Interest on Deposit Receipts, .
Interest on Consols, .
Entrance Fees from 28 new Ordinary-
Fellows,
Annual Contributions from 380 Ordinary
Fellows,
Composition for Life-Membership from
Four Ordinary Fellows, ....
Transactions sold,
£10
9
6
1
5
0
0
3
8
29
8
0
95
0
0
21
4
0 0
2 0
£563 6 2
174 16 11
£738 3 1
EXPENDITURE
Corporation Duty,
Income Tax,
Shorthand Reporters,
Commission to Collector,
Doorkeeper's Salary, .
Oliver & Boyd's Account for Vol. XXXI
of Society's Transactions (550 copies)^
Oliver & Boyd's Account for Printing
Billets, Postages, etc.,
Bent of Rooms and Carriage of Books,
Waterston & Sons' Account,
The Secretaries and Editor, for Postages,
Blocks for Illustrations,
Balance to New Account,1
£0 10
11
0 6
6
11 11
0
1 13
0
1 16
0
102 12
6
30 3
0
5 2
0
11 9
9
0 8
0
8 2
6
£173 15 2
564 7 11
£738 3 1
i Of this Balance, the sum of £250, 10s. 6d. is invested in 2£ per cent. Consols.
A
2 ELECTION OF OFFICE-BEARERS, ETC.
The accounts were audited by Dr Nicholson and Dr Dewar,
and found correct.
Dr Freeland Barbour, seconded by Dr Lamond Lackie, moved
a hearty vote of thanks to the Treasurer, which was unanimously
accorded.
II. The Society then proceeded to the election of Office-
bearers for the present Session, and the President announced
the result as follows : — President, Dr J. W. Ballantyne ; Vice-
Presidents {Senior), Dr Berry Hart ; {Junior), Dr Wm. Fordyce ;
Treasurer, Dr Wm. Craig ; Secretaries, Dr Lamond Lackie and
Dr Barbour Simpson ; Librarian, Dr Haultain ; Editor of Trans-
actions, Dr Angus Macdonald; Members of Council, Dr»K T.
Brewis, Dr Munro Kerr, Dr Freeland Barbour, Dr Haig
Ferguson, Sir Halliday Croom, Dr Samuel Sloan (Glasgow), Dr
Macrae Taylor, Dr Scott Carmichael.
III. The following gentlemen were elected Ordinary Fellows
of the Society :— E. Burnet, B.A., M.B., Ch.B., 4 Fingal Place,
Edinburgh; A. S. Walker, M.B., Ch.B., Ashleigh, Middles-
borough; Archibald Dunlop Stewart, M.B., L.E.C.S.E., 8
Brougham Place, Edinburgh ; Henry F. Gordon, M.D., L.K.C.P.
& S.E., 178 Colony Street, Winnipeg, Canada; E. A. Elder,
M.A., B.Sc, M.B., Ch.B., 6 Torphichen Street, Edinburgh; E.
W. Dyer, M.B., Ch.B., c/o Messrs Webster, Steel & Co., 5 East
India Avenue, London, E.C. ; W. T. Smith, M.B., Ch.B., Linwood,
Midcalder; Arnold Davies, B.A., M.B., Ch.B., Menai Bridge,
North Wales ; T. Graham Brown, B.Sc, M.B., Ch.B., 3 Chester
Street, Edinburgh; John B. M'Morland, M.B., Ch.B, 19
Merchiston Gardens, Edinburgh; W. 0. Sclater, B.Sc, MB.,
Ch.B., 16 Warrender Park Cresent, Edinburgh; A. G. K.
Ledger, M.B., Ch.B., Tupsley, Hereford; F. T. Greig, LE.C.P.
& S.E., (Lt.-Col. E.A.M.C., retired), 16 Melville Terrace, Stirling;
Duncan Lorimer, B.Sc, M.B., Ch.B., 7 Gillsland Eoad, Edinburgh ;
ADDRESS ON THE FUTURE OF OBSTETRICS. 3
Chas. Kobert Mitchell, M.B., Ch.B., Koyal Maternity Hospital,
Edinburgh; W. D. Osier, M.B., CM., 11 Montgomery Street,
Edinburgh ; Dr J. Halley Meikle, 44 Morningside Drive, Edinr.
IV. INAUGURAL ADDRESS ON THE FUTURE OF
OBSTETRICS.
By J. W. Ballantyne, M.D., F.R.C.P., F.R.S. Edin., Lecturer on Mid-
wifery and Gynaecology, Surgeons' Hall and Medical College for
Women, Edinburgh; Physician to the Royal Maternity and
Simpson Memorial Hospital, Edinburgh, etc.
Ladies and Gentlemen, Fellows of the Edinburgh Obstetrical
Society, — "To inaugurate," said Dr Johnson, in that famous
Dictionary of his, means " to begin with good omens," or simply
"to begin." His worthy follower in the art and science of
lexicography, Dr James A. H. Murray, in that marvel of patient
research and brilliant scholarship, the New English Dictionary
on Historical Principles, after quoting Johnson's early definition,
proceeds to amplify and lead out the meaning of the rich and
suggestive word inaugurate in this manner : " to begin (a course
of action, period of time, etc., especially of an important
character) with some formal ceremony or notable act; to com-
mence, enter upon, to introduce, usher in, to initiate." And
then our fellow-countryman, with that dry humour which breaks
out now and then even in his Dictionary, places within brackets
the following additional definition: "inaugurate, sometimes
merely grandiose for begin." Now I feel grateful to Dr Murray
for so slyly slipping that bracketed addendum into his already
full page; for I see, with relief, that I can shelter myself
behind it, and can plead that if this address fall short of being
a worthy, a notable, and an auspicious ceremonial act at the
commencement of this, the sixty-eighth session of our Society's
history, it can at least claim to be, beyond any cavilling, a
beginning.
4 ADDRESS ON THE FUTURE OF OBSTETRICS,
A valedictory address naturally enough concerns itself with
what is past, and has a ring of finality and farewell in it, vale !
vale! sounding out from it with pathetic cadence; but an
inaugural address looks forward to the future and dwells upon
it, not without hope and expectation of the good and great
things that are to come out of it, for at the very heart of the
word inaugural lies the root augur, and the augur had, of all
men, to be always looking forward. The Eoman augur was, as
we remember, or, as Dr Murray will tell us, if we have forgotten,
" a religious official whose duty it was to predict future events
and advise upon the course of public business, in accordance
with omens derived from the flight, singing, and feeding of birds,
the appearance of the entrails of sacrificial victims, and other
portents." Now, although the primary visual image thus con-
jured up can hardly be said to reside any longer in the derivative
words inaugural, augury, and august ; although, also, the augur
himself, with his staff and auspicial rites, has long since passed
into the thick mists which cover even the brightest phenomena
(and he was not very luminous ever) of a bygone age, uttering
his vale ! yet the augural spirit is not dead in these days, but
is as living and insistent now as it ever was during all the
centuries which have elapsed since man first began to ask
questions about himself and his future. In vulgar form it is
seen in the irresponsible and sensational sisterhood of the lady
palmists, the crystal-gazers, and the Sibylline vendors of wonder-
working remedies and charms. It assumes scientific shape in
the daily forecasts of the weather to be expected in these islands,
although it must be owned that the meteorologist, being limited
to observations made upon the surface of the earth, and having
no stations high up among the clouds, sometimes fails as com-
pletely in his foretelling as does the itinerant gipsy. In our
own profession we seek, in a legitimate and proper fashion of
course, to pierce the veil which hides the future from us, and
we have recourse to the bacteriologist with his opsonic index
BY DR J. W. BALLANTYNE. 5
and Widal test, to the histologist with his methods of cyto-
diagnosis and differential blood-counts, and to the cryoscopist
with his osmotic and ionic actions.
There is, in a sense, the would-be augur in us all; and,
having now in hand the giving of an inaugural address, I
bethought me that I also might try to play the augur's part and
endeavour to forecast the future of obstetric theory and practice.
If I fall far short of what you may expect ; if I fail to please
even myself (as is indeed very likely) ; if the manner and form
of the forecasting be contrary to the traditions of Inaugural
Addresses in learned societies ; if, in striving not to be dull, I
become extravagant ; and if, in seeking to restrain fancy I run
the risk of being prosaic; then let the blame rest upon the
etymologies which have led me into such difficult territories,
and please let it be remembered that after all "inaugurate"
may be only "grandiose for begin."
In Touch with the Future.
I suppose that it was one evening in the autumn that the
events I am going to relate apparently took place. I had, I
fancy, been reading about some of the marvels of modern
psychology, had been learning how a personality can be
dissociated (on paper at least), had been grasping, with some
difficulty, that the ego is not one but two or three, and had
been trying, without entire success, to understand the mysteries
of the subliminal and the supraliminal. Then I had begun to
wonder what subject I should choose for an inaugural address
to the Society which had so highly honoured me by placing me
in its Presidential Chair. I was not finding the question one
which admitted of easy solution. My mind, in freakish fashion,
began to hunt ideas, starting a new one every few minutes, and
chasing it until another idea suddenly emerged from the sub-
conscious somewhere of brainland and engaged its attention.
6 ADDRESS ON THE FUTURE OF OBSTETRICS,
The house was very quiet, and my thoughts wandered on,
undisturbed by any extraneous interruptions, save the occasional
fall of a cinder into the fireplace, or the coming of a sort of
breathless bark from my dog, enjoying doubtless the exciting
pleasure of a subconscious chase after some old enemy. Suddenly
the telephone gave one of those undecided, apocopated, monosyl-
labic tinkles that we usually leave unanswered, and regard as
due to a fault in the apparatus or an error of the operator.
On this occasion, however, I put my ear to the instrument and
whispered " Hullo ! " To my surprise an answering " Hullo ! "
very faint and distant, but quite distinct, came back. "Who
are you ? " I asked.
" One nine four nought," was the reply.
" Thank you," I said, " but I don't want to know your number ;
I wish to know who you are, and where you are ringing up from."
" I am not ringing up from anywhere," said the voice ; " you
are on the Time Exchange, and until you grasp that notion
firmly you cannot understand who I am."
" I beg your pardon," I exclaimed in great surprise ; " I have
heard of many Exchanges, but never of the Time Exchange."
" That I can quite well believe," replied my unknown cor-
respondent. "It was only on rare occasions that you in the
beginning of the Twentieth Century got switched on to the
Time System instead of the Place System ; you happen to have
been attached to-night, and I thought I might venture to ring
you up and have a talk. So, now do you know who lam?"
" I am really very sorry," I replied, " but I haven't an idea."
"I thought you might have guessed," he said. I am an
officialof the Edinburgh Obstetrical Society, and the time from
which I am ringing you up is one nine four nought, or, if you
prefer it, nineteen hundred and forty, the Centenary year of the
Society's existence. You are not forgetting," he added, "that
our Society was born in 1840, having been conceived, so to say,
in the last month of 1839."
BY DR J. W. BALLANTYNE.
For the moment I was too surprised to answer this startling
communication from the future; but I soon recovered myself
and made a suitable reply to the Centenary Official's remark.
The Future of Obstetrics.
The next question that came to me over the wires stimulated
my curiosity and determined the course of our conversation: it
was, " Now, is there nothing you would like to ask me about
obstetrics in 1940 ? "
" If you will let me get my thoughts gathered together," I
replied, " there are hundreds of questions I should like to ask
you."
"I do not promise to answer them all," replied Nineteen
Forty as I may call him, " for there are some matters which I
could not make plain to you without a great deal of preliminary
explanation, and we have not time for that ; but I will do what
I can to satisfy your curiosity."
" What sort of preliminary explanation do you mean ? "
"Well, this simply : Obstetrics has not been the only subject
of study in which there have been advances and discoveries ;
there have been great changes in surgery, still greater ones in
medicine, and a revolution in physics and physiological and
pathological chemistry ; it would require a series of lectures to
bring your general knowledge of these matters up to the level
required for the perfect understanding of all that has been
accomplished in obstetrics."
" I fully grasp the situation," was my reply. " I am now in
a position similar to that in which an old friend of mine found
himself in 1906 : he had been in Central Africa for fifteen or
twenty years, and he came back to his native land to find the
pathologists speaking the (to him unknown) language of bac-
teriology. He had the greatest difficulty in making up leeway,
and indeed never quite succeeded in doing so."
8 ADDRESS ON THE FUTURE OF OBSTETRICS,
"You are really in a worse state than he was," said Nine-
teen Forty, " but I shall try to make things as simple as I can."
Teaching of Obstetrics.
" Being a teacher," I now said, " I should like to hear about
your methods of conveying obstetric information in the year
1940."
"Ah," said my correspondent, "you were, as perhaps you
suspected, on the eve of great changes in your teaching methods
in the year 1906. You were under the intolerable burden of
having to give fifty or one hundred hours of purely theoretical
teaching in order to fulfil the requirements of the examining
boards. You delivered, each day, a lecture of an hour's length,
containing usually a bald statement of a number of facts dis-
coverable in almost any reputable text-book upon the subject ;
you occasionally tried to relieve the weariness and monotony of
your exposition by a passing reference to a specimen or a
diagram, or by the introduction of an anecdote or a personal
experience ; you adopted a didactic or a grandiloquent style, or,
worse still, you read slowly and closely from a bulky bundle of
manuscript notes. You occasionally put forceps on to the doll
in the phantom, but you lectured all the time, and you expected
your students to be taking down your words in their note-books,
when you were directing their attention to the movements of
your hands in the act of inserting the blades of the instrument.
All this was altered at once when in the University and College
Eegulations the words 'hour's instruction' took the place of
' lecture ' ; instead of having to give fifty or a hundred lectures,
you were asked to supply fifty or a hundred hours of obstetric
instruction, a very different thing, as you can imagine. Of
course some lecturers preferred to go on in the old way, and
they were at liberty to do so; but many chose to vary the
methods which had been in vogue. Here, for instance, is a plan
BY DR J. W. BALLANTYNE. 9
which was adopted not so long after the time at which you now
are. Each student was supplied with a neatly printed and
fairly full statement of the subject of demonstration to be
taken up on the following day ; to this were attached two or
three blank sheets for the noting down of additional facts, for
the drawing of a few diagrams, or for the indication of the page
or pages in a large text-book where full details might be found.
Having perused this syllabus or epitome the night before, the
student came prepared to follow and appreciate the teaching his
teacher was ready to give him. It might take the form of a
demonstration of pelvimetry in normal and malformed pelvises.
On a number of tables were several models of the well-formed
and the deformed pelvis, with callipers of various kinds lying
beside them. The teacher at first gave a very concise and clear
statement of the measurements of the diameters in the normal
and in the abnormal pelvis, and of the bearing which these
measurements had upon labour, and indicated the various ways
in which the diameters could be estimated. The class then
broke up into sections for the application of principles which
had been enunciated; and, supposing there were a hundred
students, ten men went to each of ten tables, and tested the
methods and familiarised themselves with the apparatus. On
another day the demonstration would consist of the examination
of a large number of slides under microscopes, illustrating the
appearances of placentas from two months up to the full term,
or of the uterine musculature at various stages of development.
On another day the electric phantom would be brought into
action. "
" I beg your pardon," I here interjected ; " what was the
electric phantom ? "
" It was a skilfully made model of the abdomen and pelvis
with the full-time uterus inside. By a somewhat complex
apparatus, a doll representing the foetus could be expelled from
the interior through the canals, exhibiting in its progress the
10 ADDRESS ON THE FUTURE OF OBSTETRICS,
whole mechanism of labour. The rate could be regulated to a
nicety, so that a twelve hours' or a twelve minutes' labour could
be imitated; further, the process could be interrupted at any
stage (when the head was on the perineum, for instance), and
the details explained. A student could be placed in charge of
the phantom labour at any time, the most favourite being of
course the period of vulvar dilatation and of the passage of the
head ; if he made any mistake in the method he adopted for the
delivery of the head and for the safety of the perineum, he
could be checked and shown the right plan. By the touching
of a button the pelvis could be narrowed at the inlet or outlet,
or be deformed in other ways, and by the use of dolls of
various sizes, representing mature, premature, and post-mature
foetuses, different kinds of delay or varieties of mechanism could
be exhibited. The dolls' heads were so constructed as to permit
the occurrence of moulding."
"I can quite understand the value of teaching such as
you describe," I said to Nineteen Forty; and I suppose it
was supplemented by clinical instruction in the Maternity
Hospital?"
" That, of course," was the reply, * and also at the various
small maternity sub-centres, scattered over all our large cities.
They were sets of two or three rooms, with accommodation for ten
or twelve patients, under the charge of an assistant obstetric
officer and one or two nurses ; in them normal or nearly normal
cases were confined, leaving the central institution for the com-
plicated and operative labours. But these were comparatively
early changes in our teaching methods," went on my informant ;
" others soon followed. One, for instance, was the introduction
of the kinematograph and the gramophone. By a perfecting of
the methods of obtaining differential radiograms, it became
possible to represent internal processes, such as the passage of a
stone down the ureter, or of the infant through the passages, by
the kinematograph. The pictures thus obtained were thrown
BY DR J. W. BALLANTYNE. 11
upon the screen and utilised in the teaching of obstetrics ; in
this way, for instance, the mechanism of labour could be shown
and the somewhat cumbrous and uncertain electric phantom
replaced. By the gramophone we were able to reproduce and
illustrate the cry of the parturient woman in the different stages
of labour, and the various sounds made by healthy, by premature,
and by semi-asphyxiated infants, as well as by those whose
birth had been accomplished by the use of forceps. The different
kinds of movement made by the foetus in utero (rotatory,
calcitrant, vibratory, or singultant) could be shown by the kine-
matograph, while the neophone reproduced accurately the fcetal
heart sounds and the uterine bruit."
" Stop ! stop ! " I said, " I cannot follow you any further in
your novelties of obstetric teaching."
" I was afraid you would begin to find there were difficulties
in understanding all the details," was my friend's reply, " and
yet I have only begun to name some of the new methods
invented by science for the imparting and for the testing of
obstetric knowledge. I was going on to tell you of the micro-
kinematograph, by which all embryological processes and
organogenetic readjustments could be first represented and
then reproduced upon the screen for teaching purposes. I
intended then to give you an idea of the automatic and
registering gramophone for use at oral examinations, which
excluded all conscious and unconscious bias in the testing of
candidates for degrees, for it rolled out questions in an ex-
pressionless tone of voice, and recorded without feeling the
answers given in reply ; and I was hoping to have interested
you in the great development of clinical teaching which took
place soon after 1906, and more especially after an examination
in Clinical Obstetrics was insisted upon by nearly all universities.
Perhaps, however, it would be well if I passed on to some other
subjects, for, after all, the advances in the clinical teaching of
Midwifery were already indicated and could be recognised and
12 ADDRESS ON THE FUTURE OF OBSTETRICS,
foretold by any thinking and observant man, even at the time
at which you are."
Obstetrical Societies.
" What, then, may I ask, have you to tell me about our own
and kindred societies in the Twentieth Century?" was the
next question which I put to Nineteen Forty.
"There was a great and beneficial change in the life and
activities of the various learned societies in Edinburgh soon
after 1906. By means of a munificent gift from a wealthy
man with strong scientific leanings, a large central hall to
serve as a meeting-place for all the Edinburgh societies was
built. Our own Society was, of course, one of these. But
this was found to be a suitable occasion for a rearrangement
of the energies and spheres of the different learned bodies,
and so gyntecology was united with surgery to form a large
surgical society, the Obstetrical Society devoted itself entirely
to midwifery, the Medico-Chirurgical Society became the Koyal
Medical Society by fusion with the old undergraduate organisa-
tion bearing that name (the surgical members of both allying
themselves with the newly formed surgical society), and the
Pathological Club increased its membership and instituted
Anatomical, Physiological, and Psychological Sections. Similarly,
the other scientific societies rearranged themselves. Each
society had its own afternoon or evening in the month ; but, in
addition, there were conjoint meetings on special occasions,
when, for instance, the Medical, Surgical, and Obstetrical
Societies would unite together for the discussion of subjects in
which each had an interest. The Eoyal Society was, as it
were, the mother of us all. Through the benefactions of the
generous donor already mentioned, the fee for membership was
made quite a nominal one, and the member's ticket admitted to
all the meetings, but it only conferred powers of contributing
to or speaking at one of the societies and at the conjoint meet-
BY DR J. W. BALLANTYNE. 13
ings in which that society took part. The most wonderful
part of the hall of the societies was the phonograph room ; at
least it will seem so to you," said my friend, Nineteen Forty.
u This room," he continued, " was in telephonic communication
with all the learned societies in the world, and if you wished to
hear the papers read at different places you had only to switch
yourself on to any one you might choose. In this way, you
missed none of the asides and interruptions which are so often
the very soul and life of a discussion. Furthermore, the
speaker, knowing that his words were audible all over the world,
was very careful as regards his statements, and rarely claimed
priority for any suggestion, therapeutic or otherwise."
" But what about understanding the language in which the
discussion was taking place ? " was the question which I could
not prevent myself from here asking.
"You surely do not think for a moment that the world,
and especially the scientific world, was content to go on till
1940 without adopting a universal language," was the answer
I received to my question ; and I was so taken aback by the
tone of reproach in my friend's voice that I had no remark
ready, and so lost my opportunity of finding out what the
universal language was. Before I had time to recover myself
I found that Nineteen Forty was beginning to describe to me
some of the changes which had taken place in the practice of
midwifery, and as I did not wish to miss anything of what he
was saying, I had to give him my attention,
Obstetric Practice.
" You must know," he was saying, " that the discovery
which revolutionised obstetric practice in the twentieth
century was that of a tocophoric serum."
" What was that ? " I asked.
"A serum obtained from the blood of pregnant animals
which had been treated with cultures from the blood of a
14 ADDRESS ON THE FUTURE OF OBSTETRICS,
human placenta, obtained preferably from a case of placenta
praevia," was the reply. " Its introduction into use gave us
the means of safely, speedily, and certainly inducing healthy
action of the .uterus. In this way a labour could be brought
on and a child born with almost the same degree of certainty
with which it used to be possible to perform a surgical opera-
tion. The day, and in some cases even the hour, could be
arranged, and a midwifery case became a certain part of the
day's work instead of an uncertain contingency in the middle
of any night. In the nineteenth century the introduction of
anaesthesia abolished the pains of labour and brought in a
new era of obstetric advance; in the twentieth century the
discovery of this tocophoric serum did away with the
uncertainty of the supervention of labour, and had an almost
equally great influence upon our subject. The profession
earned the gratitude of countless patients, who said something
like this : ' In the past you relieved our pains and sent us to
sleep in the midst of our agony; but now you have released
us also from the intolerable bondage of our uncertainty, and
we thank you for this new boon.' Post-mature confinements,
with their risks and delays, were in this manner done away
with ; a time suitable alike for patient, nurse, and obstetrician,
and calculated as accurately as possible to coincide with the
full term of pregnancy, was fixed upon; and the labour was
conducted with the same care and aseptic precautions as a
gynaecological or other operation."
" But what about premature labours ? " was the question
with which I here checked my friend's flow of description.
"I expected that remark," was his reply. 'You must
know that the special investigation given to the pathology
of pregnancy in the early part of the twentieth century bore
good fruit in the discovery of means of successfully preventing
the premature termination of pregnancy, and such abnormal
labours became very rare. At the same time the tocophoric
BY DR J. W. BALLANTYNE. 15
serum gave us a means of interrupting pregnancy, when for
medical or obstetric reasons (such as pelvic contractions, heart
disease, etc.) it was regarded as desirable so to do."
The Falling Birth-Kate.
"But the great principle of obstetric practice in the
twentieth century," continued my informant, " was the securing
of the safety of the infant."
"You mean," I said, "that the falling birth-rate forced
obstetricians everywhere to reconsider all their methods,
operative and otherwise, from the standpoint of the life of
the infant ? "
"Yes, indeed," was the reply; "and I shall now try to
make this plain to you. I must introduce some statistics to
bring out my meaning, but you, of course, can take your ear
from the instrument if you are bored."
" Truly, I shall do no such thing," I protested.
"In 1906 the falling birth-rate in our own and in all
civilised lands was at length beginning to attract the attention
it deserved. The birth-rate for England and Wales was 35*2
for the decade 1865-1874; it was 347 for the next decade;
for the next period of ten years (1885-1894) it had fallen to
31'2; and during the last ten years (1895-1904) it has sunk
to 29*0. So much for England and Wales. Sir Henry
Littlejohn had a still more depressing account to give of
the capital of Scotland. In 1871 the natality in Edinburgh
was 34*8 (almost the same as that of England and Wales at
the same time) ; in 1881 it was 32'2 ; in 1891, 28'2 ; in 1901,
24-99; and in 1905 it was 22-99.1 Even with these figures
1 The figures for 1906 are now available : the number of births was
7042, and the birth-rate was 22'41 per 1000. The descent, therefore,
is steadily going on, and the number of babies born in 1906 is actually
less than the number in 1881, although the population has so greatly
increased.
16 ADDRESS ON THE FUTURE OF OBSTETRICS,
before you the full gravity and meaning of the position was
not recognised in 1906. In order to grasp the significance of
the movement, look at the matter thus. In 1881, when the
population of Edinburgh was (in round figures) 228,000, the
number of babies born was 7360 ; in 1905, when the population
had increased to 336,000, the number of babies born was 7741,
whereas, if the rate had been maintained, it ought to have been
10,846. There was therefore a shortage of over 3000 babies.
It is only fair to the country in general to state that Edinburgh
occupied almost the worst position in this matter of a falling
birth-rate. Of the sixteen large towns of England and
Scotland, there was only one (Bradford) that had a lower
birth-rate than Edinburgh; and while London registered 27,
Dundee had 28, Manchester, Birmingham, Aberdeen, and
Leith had 29, Glasgow and Greenock had 30, and Liverpool
had 33."
" But," I here interruped, as my friend paused to note the
effect of these undeniably startling figures, "the death-rate
had fallen as well as the birth-rate, and so we were no worse
than we were before."
" Let us take the Edinburgh statistics again," was the reply.
"In 1881 the death-rate was 1886; in 1905 it was 1425, the
lowest ever reached till then. While, however, the death-rate
was slowly falling from 18 to 14, the birth-rate had come
rapidly down from 32*23 to 22*99. If this rate of descent had
in each case been maintained for another quarter of a century
the two rates would have reached almost the same figure, and
any increase in the population of Edinburgh would have had
to be put down to immigration, for the birth-rate had been
falling much more quickly than the death-rate. Further, while
it was conceivable that the natality of Edinburgh would
continue to fall till it reached a vanishing point, it was
not thinkable that its mortality would do likewise. There
might come a year when there were no births, but it could
BY DR J. W. BALLANTYNE. 17
hardly be expected that in that year there would occur no
deaths. All these things, however, were to the inhabitants of
Edinburgh in 1906 as idle tales; they heeded them not. And
yet, to Edinburgh obstetricians at least, the subject of the
falling birth-rate was a grave problem, and it became no
less grave as the twentieth century proceeded on its way. To
put the matter very practically," said Nineteen Forty, "there
were many more doctors settled in Edinburgh in 1906 than in
1881, but the number of babies being born. was practically the
same. I expect some of you had shrinking lists of midwifery
engagements to deplore, but I forbear to press the point."
" Can you give me now any hints as to the way in which
obstetricians in the twentieth century met the dangers of the
falling birth-rate ? " was my next question.
"That I will gladly do," was my friend's answer; "but,
first, I must point out what perhaps was little recognised or
altogether overlooked in 1906. I refer to the aggravations of
the falling birth-rate."
The Aggravations of the Falling Birth-Kate.
" What were these aggravations ? " I asked.
"In the first place, there was the infantile death-rate.
You were proud, in 1906, of the fall that had taken place in
the general death-rate of the country during the preceding
half century, and your pride was justified; for there had
been a reduction by more than fifty per cent, of the number
of deaths between the ages of five and twenty-five years,
and between twenty-five and thirty-five there had also been
a notable decrease. But there was one circumstance about
which little was said, and about which no pride could be felt :
the infantile death-rate was practically unchanged at the end
of these fifty years of hygienic progress and material advance-
ment. To quote from the Report of the National Conference
B
18 ADDRESS ON THE FUTURE OF OBSTETRICS,
on Infantile Mortality (p. 99), held in London in June 1906 :
'In the twenty years ended 1874, we find that out of every
1000 children born alive in England and Wales, 153 never
completed their first year, while in the twenty years ended
1904, the ratio was 148 per 1000.' There was, it is true,
a slight improvement — 148 instead of 153 — but was it an
adequate, a satisfactory, even a noteworthy degree of improve-
ment, when contrasted with the fifty per cent, improvement
between the ages of five and twenty-five? This, then, I
call the first aggravation of the falling birth-rate : fewer babies
were being born, and yet they were dying off practically as
rapidly during the first year of life as they had ever done.
"A second aggravation was your ignorance, in 1906, of
the stillbirth-rate and the abortion-rate of your country. You
did not know how many pregnancies ended in the birth of
infants who never lived outside the mother's uterus, who,
in the words of one of the nineteenth century poets, exchanged
cthe amnios-skin of this world for the shroud, the amnios-
skin of the next.' You hoped, perhaps, that fewer stillbirths
were happening, but you dreaded lest your hopes should turn
out ill-founded ; at any rate you did not know, for there was
no registration of stillbirths to reveal the frequency of
such ante-natal catastrophes. In reality, a steady increase
was going on, as Dr Kaye's Yorkshire statistics, local though
they were, proved. He found that in 1901 there were 47*6
stillbirths per 1000 livebirths, and the number steadily
increased until in 1905 it was 56*3. 'Apply these figures/
said Dr Kaye {Report of the National Conference on Infantile
Mortality, 1906, p. 104), 'to the whole country (England and
Wales), and it means that the number of stillbirths has grown
from 44,270 in 1901 to 52,350 in 1905, an increase of over 18
per cent., while the total livebirths have decreased in actual
numbers/ Then as to the abortion-rate, you must surely,"
said the Official of 1940, '' have had some feelings of dismay
BY DR J. W. BALLAD TYKE.
19
when, in 1906 and in preceding years, you reflected upon the
wastage of ante-natal life by reason of abortions. You could
hardly shut your eyes to and stop your ears against the
testimony of text-books and journal articles which, with
striking unanimity, attested the frequency, the growing
frequency, of abortion. Some placed the frequency of mis-
carriage at one to every three or four pregnancies; others
stated that one in every five gestations ended in abortion."
Here I interrupted my informant with the remark that
I did not think the abortion-rate was so high as that.
" What reasons have you for doubting it ? "
"Well," was my reply, "in the last series of 100 indoor
labours under my care in the Edinburgh Eoyal Maternity
Hospital there were not many women who gave a history
of having aborted."
"But," said my friend, "did you exclude the primiparas
and the women under thirty years of age ? "
" No," I replied.
" Suppose you do that ; how do your statistics stand now ? "
"In the 100 cases there were 21 women of thirty years of
age and over, and of them 8 gave a history of previous
abortions."
" There you are," said Nineteen Forty in triumph ; " thirty-
eight per cent, of your patients who had reached the middle
of reproductive life had aborted ! Besides," he continued,
"you had only the patients' word for the number of their
abortions; it is much more likely that they under-estimated
than over-estimated the frequency of such occurrences, especially
early miscarriages of six weeks. You must, after all, admit
that not fewer but more abortions were occurring in Great
Britain in the early years of the twentieth century. There
was yet another aggravation to the falling birth-rate, to which
I must, for a moment, refer. That was the curiously significant
increase in the number of deaths ascribed to premature birth
20 ADDRESS ON THE FUTURE OF OBSTETRICS,
which began to be noticeable in the mortality returns. The
infantile mortality from premature birth, which in 1865-1874
was 11-9 per 1000 (for England and Wales), had in 1875-1884
grown to 13-7, in 1885-1894 to 168, and in 1895-1904 to 198.
The most striking thing about this increase was that it began
as soon as and no sooner than the birth-rate commenced
to decline. One can hardly refuse to ascribe some significance
to that fact.
"Now, let me gather together these various statements,"
said Nineteen Forty, "and you will see better how you really
stood in the year in which you are living. The infantile
death-rate, notwithstanding all recent advances in hygiene
and the laborious study of the diseases of infancy, was no
better than it was fifty years previously. There was reason
to believe that the number of stillbirths and abortions
was increasing; and these, although they constituted deaths
in a real sense if not in a forensic one, were not included
in the mortality tables. The number of infantile deaths
ascribed to premature birth was increasing, pointing to a
probable increase in the total number of premature births
occurring. Finally, there was the progressive and serious
fall in the birth-rate. What could the obstetricians of the
twentieth century do but strive to counteract these evils ? "
Checking the Falling Birth-Eate.
" How did they check the falling birth-rate ? " was my
question, for my informant at this stage in our conversation
seemed to expect me to say something.
" They did not check it, they could not check it," was
the startling reply; "but they checked the aggravations
of it, and so secured some salvage from the wreckage of
life which was occurring before, at, and immediately after
birth. This salvage more than compensated for the decline
BY DR J. W. BALLANTYNE.
21
in the birth-rate, and thus the civilised nations of the earth
were able to maintain their position to some extent, at any
rate, if not entirely. So now you see why I so strongly
emphasised the aggravations of the falling birth-rate. But
matters got much worse before they began to improve."
" In what way ? " I asked.
" I will tell you," was the reply.
" The checking of the falling birth-rate was, as I have said,
not an obstetrical problem at all ; at least it was not one which
obstetricians could hope to solve. The falling of the birth-rate
was not due to less knowledge or less skill in the obstetricians
of the day, or to want of training of the midwives and monthly
nurses, or to the neglect of chloroform or the forceps, or to
the excessive use of these means of relieving pain and hastening
the second stage of labour, or, indeed, to any other thing which
lay in the power of the medical man to do or leave undone.
The causes lay deep among the roots of the somewhat artificial
conditions of the sexual relationships in modern society. A
nineteenth century writer (Kenan) said : ' The spread of an
enlightened selfishness is, in the moral world, a fact of the
same nature as the exhaustion of coal-fields in the physical
world; in each case the existing generation is living upon
and not replacing the economies of the past.' His words
apply very exactly to the enlightened selfishness which was
the root-cause of the falling birth-rate. The era of personal
comfort first, and at any cost ; the age of late marriage, because
the entrants upon the matrimonial state wished to begin, not
where their parents began, but where they were prepared to
leave off; the period of frequent holidays and expensive
amusements could hardly be described as other than ' selfish/
although it might be doubted whether it deserved the honour
of being entitled ' enlightened.' In any case, such an age was
not one in which frequent child-bearing was likely to be
thought of with favour, or carried through with enthusiasm.
22 ADDRESS ON THE FUTURE OF OBSTETRICS,
If there was ergophobia in the one sex, there was maieusophobia
in the other. Nor was a popularisation of the knowledge
of the nature and mode of use of ' checks ' to conception likely
to raise the average size of families.
"Matters did not improve after 1906. In fact, it was not
long till rumours began to circulate regarding the existence
of a new institution, the ' City without a Child,' a sort of
municipal agennesia, wherein mental productivity and financial
success were held in high esteem, while the reproduction of the
race was nothing accounted of. The inhabitants renounced the
pleasure and the honour of having families, but gladly accepted
all other pleasures and honours that came in their way. The
citizens occupied their days in making money, and their nights
were not spent round the fireside in the home. They were
described as curious places, these experimental childrenless
cities : no schools, no toy-shops, no Christmas-trees, no happy
young boys and girls on the roadways; nothing but hard-
visaged men and steel-eyed women, and bustle and racket, and
vain hopes and restless desires; and by-and-by an alarming
increase in the frequency of suicide, and in the number of the
inmates of the palatial asylum which stood upon a hill
overlooking the town. So, in the end, the attempt to reduce
the birth-rate to nil was the cause of its gradual ascent again ;
and the experiment of race-suicide was in that sense a failure.
"In the meantime the medical profession, and especially
the obstetricians, had been busily endeavouring to save some-
thing from the wastage of ante-natal life, and to keep alive
many of the new-born infants who formerly used to succumb
to death in various forms during the first few months of post-
natal existence."
Estimation of the Wastage of Ante-natal Life.
"In the first place," continued the Official of 1940, "the
BY DB J. W. BALLANTYNE. 23
obstetricians of the early part of the twentieth century set
themselves the task of estimating the annual loss of life at
and before birth. With the help of a Stillbirth Eegistration
Act, and with the assistance of the army of skilled monthly
nurses which the Mid wives Bill had called into being, statistics
of stillbirths and abortions were obtained. The results were
startling, appalling in fact; but after the first excitement
incident thereupon had died down, it was seen that in the very
magnitude of the loss of ante-natal life that had been going on
lay the hope of the future. By diminishing the ante-natal
death-rate, by checking the frequency of abortion, it was
recognised that there was a means ready to hand to counter-
balance the falling birth-rate. If a fifth of the stillbirths and
abortions could be prevented, it was seen that the loss accruing
from the smaller number of births would be compensated.
Further, it was discovered that many of the cases which went
to produce the high infantile mortality of 148 per 1000, during
the first year of life, were deaths of prematurely born infants.
So it became apparent that to check the frequency of premature
births would give a means of reducing the high infantile death-
rate; in this direction also there lay compensation for the
failing birth-rate. You can almost forecast for yourself now
the lines along which obstetric practice began to advance," said
my friend of 1940; "but I will indicate them very briefly."
Study of Pregnancy, Normal and Pathological.
" The hygiene of pregnancy began to be studied in detail and
with an enthusiasm and thoroughness never before arrived at.
Patients were encouraged to consult their medical attendants
regarding the rules of health in pregnancy, and the latter were
prepared to give the advice sought. It was recognised that
pregnancy was a severe and a long-continued testing of the
structural and functional integrity of all the organs of a
24 ADDRESS ON THE FUTURE OF OBSTETRICS,
woman's body. It was soon seen that while an unmarried or
a non-pregnant woman might with impunity, or apparent
impunity, break many of the laws of hygiene, a pregnant
patient did so at her peril ; and every medical man made it his
duty to revise with the pregnant patients all the rules relating
to the care of the bodily functions, putting right what was
wrong, and warning against possible errors in diet, clothing,
habits, and the like.
"Further, in cases of doubt, consultations were freely asked
for and given, it being recognised that it was better to check
the beginnings of evils in pregnancy than to wait till an
abnormal gestation had developed into a labour dangerous for
infant and mother alike. Whereas in your time," said my
informant, " consultations in pregnancy were seldom asked for,
save to determine whether the induction of abortion should be
carried out in order to try to save the mother's life at the
expense of that of her foetus, in the new era the specialist was
called in early enough for his remedial measures to avail both
the maternal and the infantile lives. In this way, not only
were pathological pregnancies often prevented altogether, but
in many instances they were so energetically treated in the
early phases that they yielded to therapeutic means that would
have been of no use at later stages. Eclampsia was one of the
first of the gestational maladies which began to benefit by such
a revolution in the management of pregnancy. Whereas it had
been common for the urine of a pregnant patient never to be
tested — indeed, in many cases it was not customary for the
medical attendant to be told about the pregnancy or summoned
to the patient till labour was in the first stage — now, the doctor
was engaged to look after his patient in the early weeks of her
pregnancy as well as in the hours of her labour and in the days
of her puerperium. His duties included regular analysis of the
urine, as well as the supervision of all the details of the gesta-
tion, and the correction of any of the symptoms which might
BY DR J. W. BALLANTYNE.
25
arise. The obstetrician of 1940 finds it difficult to understand
why his brethren of the early part of the century paid so much
attention to the one month of the puerperal period and so little
to the nine months of pregnancy. To him the time of pre-
paration for labour was not less but more important than the
time of recovery from the effects of labour, for he found that if
the former was normal the latter was little likely to be
pathological.
" Along with this development of the study of the manage-
ment of pregnancy and of the treatment of the disorders of
the pregnant state came a marked advance in the knowledge of
ante-natal maladies. The mystery of trans-placental trans-
mission was elucidated, and stillbirth by reason of foetal diseases
and defects became rare. So-called 'habitual' abortion and
intra-uterine death were soon shown to be due in every instance
to some definite and ascertainable cause ; and the hopelessness
which had previously characterised all attempts at treatment
gave way to the enthusiasm inspired by frequent success.
New and more effective means of keeping prematurely born
infants alive were adopted with the best results, and the
favourite British operation of the induction of premature
labour for contracted pelvis took an enhanced position of
esteem among other methods of obstetric intervention. As I
have already said, the appreciation of the value of foetal life
was the fact which dominated obstetric theory and practice in
the twentieth century. Embryulcia, craniotomy, and all such
destructive procedures yielded to methods which gave a chance
of survival to the child, and thus Cesarean Section, Vaginal
Section, and the Induction of Premature Labour took their
rightful place in the list of obstetric operative measures. By
means of the knowledge which obstetricians gained regarding
the state of their pregnant patients {eg, by pelvimetry,
physical examinations, etc.) it was possible to detect pelvic
contractions, tumours, and the like before the supervention of
26 ADDRESS ON THE FUTURE OF OBSTETRICS,
labour, and so to avoid interference at the time when the
occurrence of the phenomena of childbirth was the cause of
additional risk and danger. For instance, it became rare for
a medical man to be summoned to a full-time labour in which
there was an undetected pelvic contraction, and thus, emergency
Cesarean Sections or (worse still) craniotomies were hardly
ever heard of."
The Problem of Cancer.
" I have greatly benefited by what you have told me," I said
to Nineteen Forty; "but can you satisfy my curiosity about
one other matter ? It is scarcely an obstetric problem, perhaps,
but it is a very pressing one : I refer to the discovery of the
cause and cure of cancer."
" I cannot reveal much," was the reply, " but I am permitted
to throw out some hints. For instance, it was not long after
1906 that it came to be recognised that there was a curious
parallelism between great philanthropic movements and note-
worthy life-saving and pain-relieving discoveries."
" What do you mean ? " I queried. " Well, take the case of
the abolition of slavery in the British possessions at a cost of
£20,000,000 ; that was a great and a beneficent and an unselfish
act on the part of one section of mankind for the amelioration
of the condition of another and a suffering section ; it was soon
followed by the discovery of anaesthesia — that priceless boon.
Of course, the anaesthetics themselves had been in existence for
years, but their effects were till then unknown."
"I think I see what you mean," I said; "and was there
any great philanthropic advance pending in 1906, or soon there-
after, which made it possible for the discovery of the cause
and cure of cancer to take place as a corollary thereto ? "
My friend hesitated a little before he replied, and then said
slowly: "The greatest boon that mankind could voluntarily
BY DR J. W. BALLANTYNE.
27
bestow upon itself would be the abolition of war, would it
not ? "
" You think," said I, " that it was that great international
blunder — the appeal to arms to settle disputes — that was
delaying the discovery of the cure of cancer ? " My informant
did not answer this question; at least, if he did, I, in my
excitement, failed to catch his reply. So I went on and said
to him : " I myself have of late years been inclined to look to
the chorion-epithelioma and its embryological relations for the
elucidation of the problem of the origin of malignancy ; but I
have a friend who believes that the secret lies in the hands of
the botanists. He is sure that in the differences of the life-
conditions of fungi and bacteria are to be found the explanation
of the origin and the theory of the cure of cancer."
" Tell him to make experiment," was the reply which came
to me somewhat indistinctly, for it appeared as if my telephone
were not recording very clearly. I spoke again, but it seemed
as if the connection had been cut ; so, as I did not wish to be
rude, I asked for the Time Exchange, No. 1940, and got
switched on again. " I wished to thank you very warmly for
so kindly giving me so much information about the future,"
I said. uCan you answer one other question, a personal
one ? " I asked. " You described yourself at the beginning of
our conversation as an Official of the Obstetrical Society of
1940 ; can you give me no other clue to your identity? "
" I am the President," was the reply.
" Indeed, then," I said, " I am highly honoured, sir, to have
made your acquaintance."
I heard what sounded like a laugh, and then this rejoinder
came back to me over the wires : " You call me sir, but is it
impossible that the President of 1940 should be a woman ? "
I awoke with a start, to find my telephone ringing furiously ;
and a call to a serious case at the Maternity Hospital was soon
engaging my thoughts. But I have sometimes wondered
28 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,
whether it was all a dream; whether it was not in part an
" uprush of the subliminal consciousness/' as the psychologists
call it ; whether it was not, in certain details, a vision of that
future so rapidly advancing upon us, when —
Much that is wrong shall be righted,
And man shall see, never affrighted,
Clearly his duty, and do it,
E'en if his life-blood go to it.
On the motion of Br Ritchie, seconded by Br Craig, a hearty
vote of thanks was unanimously accorded the President for his
address.
V. THE MANAGEMENT OF SOME DIFFICULT
OCCIPITO-POSTERIOR CASES.
By J. Lamond Lackie, M.D., F.R.C.P. Ed., Assistant Physician, Royal
Maternity Hospital ; Lecturer on Obstetrics and Gynaecology,
School of Medicine of the Royal Colleges.
Until quite recently, I had been in the habit of thinking,
and indeed sometimes of teaching, that when the obstetric
forceps slipped off the head during the operation of extraction,
the instrument had been unskilfully applied. "Within the last
month I have changed my views on this point entirely. Up
till October of this year I had no personal experience of the
accident, but during that month I had two consecutive cases
in which the forceps slipped, and these form the basis of the
present communication.
Case I. — Mrs D., set. 29, primipara, went into labour on
Thursday, 4th October, at 2 A.M. The pains at first were slight
and very occasional, but the membranes ruptured at 10 A.M. ;
and at 11 A.M., when I first saw her, the os was only the size
BY DR J. LAMOND LACKIE.
29
of a shilling. It dilated very slowly, and little progress was
made all Friday. During the night the pains were stronger,
and at 10 a.m. on Saturday the os was 3 inches in diameter,
and a right occipito-posterior position was diagnosed. Pains
were strong till 3 p.m., but on examination one found that
since 10 a.m. absolutely no progress had been made, and the
anterior segment of the cervix had become oedematous. At
4 p.m. the patient was exhausted, and inertia uteri had set in.
Chloroform was administered, and the dilatation of the os
completed by the fingers. Forceps were then applied to
the head, which was well engaged in the pelvic inlet. Strong
traction seemed to make no impression, and suddenly, during
an extra effort on my part, the forceps came away in my hands.
The sensation, to say the least of it, was unpleasant ; one felt
that one had fractured or dislocated something, but I take it
that the click one feels and hears is simply due to the sudden
excessive overriding of the cranial bones which the closed
forceps causes as the instrument comes over the head. For-
tunately, the damage to the mother's soft parts was slight, but
the vulva was somewhat torn by the escaping forceps. I then
tried to flex the head and rotate it, but, as I almost expected,
my efforts were fruitless, as the head was too high up and too
fixed. Forceps were again applied, and appreciating the fact
that the occiput was to the back, I endeavoured to apply the
blades in that region. Again the forceps slipped when I
pulled, and this not once but several times. The instrument
was not each time forcibly pulled out of the vagina, as I was
always on the outlook for slipping. Here, I may say, that by
grasping the application handles, as well as the traction handle,
I was better able to appreciate whether the blades were to
slip or not; one seemed to be more in sympathy with the
position of the blades by sensation conveyed through the
handles than through the traction rods. Ultimately, one
seemed to find a grip that held, well back over the occiput,
30 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,
and the head was born face to pubis, but only with great
difficulty, and after the expenditure of much force in traction.
There was some laceration of the perinseum. The child, a
female, which weighed 9 lbs., was apnceic, but recovered, though
it showed signs of compression for two or three days. It is
now very well, but has a marked internal strabismus of the
right eye, which, however, is now improving. The mother had
a normal puerperium. I ought to mention that she was a
woman of average stature, and there were no obvious signs of
any deformity of the pelvis. This, then, was simply a per-
sistent occipito-posterior case, delivered in the usual way by
forceps — the only peculiarity being the slipping of the forceps,
which shows how excessive was the traction necessary for
delivery. I have quoted the case as a contrast to the two
which follow.
Case II. — Mrs W., set. 30, ii.-para, expected her confinement
on 10th October, but this did not take place till 28th October.
Pains commenced at 2 a.m. ; at 4 A.M., when I saw her, the os
was nearly but not quite fully dilated. Eight occipito-posterior
was the position. At 5 A.M. the membranes ruptured and the
liquor amnii began to trickle away. The cervix was still not
fully taken up. At 8.30 a.m. there was no change, except that
the anterior segment of the cervix had become oedematous.
Pains were now slight, and made no impression on the advance
of the head, which remained at the brim. Under chloroform,
forceps were applied, and, to my surprise, I repeated my
experience of 6th October. The forceps came away in my
hands with, fortunately, no damage to the mother. I reapplied
them, still remembering the position of P.O. P., but the result
was the same, and no matter how carefully I applied the
instrument well back towards the promontory of the sacrum,
the forceps, whenever traction of any degree was employed,
came over the head with that click which is so suggestive of
BY DR J. LAMOND LACK IE.
31
serious injury to the child. I applied the forceps no less than
six times, but I could not get the head to enter the pelvis. I
then tried to turn the child's head round so that the occiput
should be to the front, and at the same time I endeavoured to
turn the shoulders by external manipulation; but though I
could move the head I could not turn the shoulders, and
before I could get the forceps applied the head was back to its
original position. Finally, I introduced my hand past the head,
and with two fingers on the right shoulder and my left hand
acting through the abdominal wall, with great ease I turned the
child round till it occupied the L.O.A. position. Once more
I applied the forceps, and with comparatively little traction
the child was born within three minutes. It weighed 10 J lbs.,
but seemed to have suffered no injury except facial paralysis,
which passed off in three days. The mother had a normal
puerperium. She was a woman of medium height, and had
no pelvic deformity. I delivered her of her first child exactly
four years previously, when the labour was almost normal,
forceps being applied only to bring the head over the perinaeum.
Case III. — I hoped I had done with difficult E.O.P. cases
for the month, but I was mistaken. On Tuesday, 30th October,
at 10 a.m., I was called to Mrs B., iii.-para, who had been in
labour since 4 a.m. The os was the size of half a crown. At
3 p.m. the liquor amnii began to trickle away. At 5 p.m. the
os was nearly, but not fully, dilated ; the position was E.O.P. ,
and the head was high up and movable at the brim. At 9 p.m.
there was no change, and inertia uteri had set in. The patient
was chloroformed, and first of all I applied forceps, but the
locking was so unsatisfactory that I was not surprised that
traction proved useless, and I therefore soon desisted. Eemem-
bering my experience of two days before (Case II.), I determined
to try internal rotation of the head. I removed the forceps,
then pushed the head upwards, and by internal and external
32 MANAGEMENT OF DIFFICULT OCCIPITO-POSTEFJOR CASES,
manipulation turned the head round till the vertex lay in the
RO.A. position. A pain came on and fixed it there, and as
rapidly as possible I applied the forceps. Extraction was
quite easy, and a living child was born, 9 lbs. in weight, with
no signs of damage at all. The interesting point about this
case was that the patient had been confined twice before, nine
years ago and seven years ago, and on both occasions she was
very ill, instruments were used, and both children were born
dead, having died, the mother tells me, during birth. I cannot
help thinking that but for artificial internal rotation the result
would have been just the same on this occasion.
The first and the second and the third cases which I have
narrated form a striking contrast. The first was a primipara
who presented all the usual features of a malposition of the
head — a slow first stage, premature rupture of the membranes,
and oedema of the anterior segment of the cervix, which one
notes seems in these cases always to hang free in the pelvis
between the head and the outlet. The second stage was
delayed, the descent of the head was only partial, spontaneous
rotation did not occur, the forceps slipped several times, but
ultimately the patient was delivered simply by excessive
forceps traction. Had forceps failed, one had to think of
craniotomy, symphysiotomy, or pubiotomy. The second and
third cases presented the same preliminary feature as Case I.,
but the head was still movable at the brim. There were several
possibilities of treatment had forceps ultimately failed —
Cesarean section, embryulcia, etc. — but the whole object of
this paper is to emphasise the fact that to rectify a malposition,
if diagnosed early, is possible and sometimes easy. I have
rarely been so struck with the effects of treatment as in the
second case, where what proved almost an intractable case
became quite suddenly, by simply rotating the child, one of
the easiest high forceps cases I have ever experienced. The
BY DR J. LAMOND LACKIE. 33
child was large, it was post-mature, but once it was placed
in a normal position it was delivered in a very few minutes.
Before resorting to a more serious obstetric operation, such as
craniotomy, I should certainly have performed internal version,
which is generally recommended in these cases, but the chances
for the child would then have been much diminished. Every-
thing was no doubt favourable for artificial rotation : the head
was still not properly engaged, the liquor amnii had not all
escaped, and the patients were multiparas. Since in nine cases
out of ten an E.O.P. rotates so that the occiput comes forward,
one would not attempt this operation if the head were descend-
ing with the pains ; one would simply further rotation chiefly
by increasing flexion. In all text-books reference is made to
artificial rotation of the head when it has reached the pelvic
floor, and this is common practice ; but only in a few, and these
are foreign, is rotation when the head is high up recommended
as a possible method of treatment. I am not sure that in this
country the value of artificial rotation of the whole child when
the head refuses to enter the pelvis has been duly appreciated.
Under the circumstances which prevailed in Cases II. and III.,
I should be inclined, if an E.O.P. were diagnosed early, to again
try artificial rotation, rather than risk a very difficult forceps
case — a possible sacrifice of the child by version, or a certain one
by embryotomy.
Br Barbour was much interested in Dr Lackie's communica-
tion, which drew attention to a method of dealing with occipito-
posterior cases which was not sufficiently recognised in this
country. It was noteworthy that the head was delivered with
much greater ease, lying in the same diameter, with the occiput
to the front instead of to the back, because the difficulty was
evidently in this case not in the longer rotation the head had
to undergo, but in some cause interfering with its engagement,
C
34 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,
or with proper flexion. The cause of deficient flexion in
occipito-posterior positions was not evident. It had been
ascribed to the promontory, but this explanation was not
adequate. He congratulated Dr Lackie on his successful
management of these cases.
Dr Haig Ferguson cordially thanked Dr Lackie for his
interesting and suggestive paper. All present, no doubt, had
had experiences such as Dr Lackie's in the slipping of forceps
in occipito-posterior cases. In his opinion, this slipping was
due to the head being extended and the forceps grip being too
near the sinciput and not sufficiently far back on the head.
This could be rectified by promoting flexion of the head by
manual manipulation, after which the forceps can generally be
applied satisfactorily without fear of slipping. When the
forceps is applied when the head is extended, traction simply
tends to keep up, if not to increase, the extension, and so the
delivery of the head is not by any means facilitated even when
the blades do not slip off the head. He was much interested
to hear that by an apparently comparatively simple manoeuvre,
as Dr Lackie described it, a right occipito-posterior position,
as in Case II , was converted even into an L.O.A. He would
certainly try this method of artificial rotation the next
suitable opportunity he had, as it seemed not only rational, but
eminently calculated to conserve fcetal life, a point so strongly
and rightly insisted on by the President in his address just
delivered.
Dr James Ritchie felt indebted to Dr Lackie for having
reported cases showing the ease with which in posterior
positions, under suitable conditions, the body of the child could be
rotated. Kotation of the head alone was not satisfactory. He
thought that the chief reason why delivery was more difficult
in posterior than in anterior positions lay in the fact that,
in consequence of the projection of the promontory there is less
room at the posterior end of the oblique diameter than in front,
BY DR J. LAMOND LACKIE.
35
and that the sinciput, being smaller, passes more easily than
the occiput.
Br Dewar thanked Dr Lackie for his eminently practical
paper. Papers such as the one read were a great help to the
practitioner in his everyday life, inasmuch as they refreshed
the memory by recalling some of the principles in the treat-
ment of difficult cases, which are apt from infrequent application
to become dim in the mind. In thinking over those occipito-
posterior positions, one or two thoughts had occurred to him.
A medical man was sometimes called to a labour case at a very
early stage. It was very customary for him, after making the
usual vaginal examination and finding the os undilated or only
very slightly dilated and the passage dry, to heave a sigh, perhaps,
if it should be three o'clock in the morning, and tell the patient
and her friends that, as labour was hardly commenced, he
would go home, and come back in the morning. He confessed
that he used to follow such a practice, but experience had
taught him to adopt a different method, which he had now
practised for many years. By being content with a simple
vaginal examination the medical man missed his best opportunity
of rectifying an abnormal position if it should be present. His
routine practice was, if the os was undilated, to make an abdominal
palpation, as he was anxious to find out, if possible, what presenta-
tion and what position he had to deal with. It was easy to read
in the text-books what to do in difficult cases, but it was not so
easy in practice ; yet, with patience and a little care, if such an
opportunity occurred, it was fairly easy, by palpation, to make out
whether the presentation was a transverse, a breech, or an
occipital one. If occipital, he should try to satisfy himself
whether the position was occipito-anterior or occipito-posterior ;
if the latter, he should then endeavour to rectify at once, as it is
very much easier to rotate the child at that stage, when the
membranes were still intact, than at a later stage, when the head
was engaged in the brim or in the pelvic cavity. If, however,
36 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,
the case was not seen till at a later stage, he favoured internal
rotation by the hand rather than by the forceps, as being less
dangerous to both mother and child. He narrated the difficulties
of an occipito-posterior case, in which the persistence of the
position was probably due to the tip of the coccyx projecting
forwards at a right angle to the sacrum, and thus diminishing
the antero-posterior diameter of the pelvic outlet to something
like 3| inches, which was certainly too little to allow the passage
of the occipito-frontal diameter of the head, which would be
at least not less than 4J inches. The position remained a
persistent posterior one, in spite of all his endeavours to rectify
it, and while attempting to deliver with forceps, a snap was
heard, after which the head was extracted in the ordinary way
of K.O.P.'s. The coccyx was fractured. In the patient's
second labour the same difficulty occurred, the coccyx having
united at a similar angle. On this occasion, profiting by the
experience of the previous labour, he forcibly fractured the
coccyx with his fingers, so as to avoid damage to the occiput,
which was present in the first labour, and delivery was com-
paratively easy. On the third occasion, with the tip of the
coccyx in the natural position, the position was an R.O.P. again,
which very soon rotated into an anterior position, and the
child was born without assistance, showing that the peculiar
position of the coccyx in the first two labours was the cause of
the failure of rotation. With regard to the question raised by
Dr Barbour, as to why the head, when rotated from the posterior
to the anterior position, should engage in the brim more easily,
Dr Dewar thought that an answer would be found in the fact
that after rotation above the brim, the belly of the child would
adapt itself to the concavity of the uterus and pelvis behind,
the spinal column would curve correspondingly, and the occipito-
spinal joint coming behind the line of the uterine force, flexion
would take place, allowing the head to pass easily through the
pelvic inlet in the wide oblique diameter.
BY DR J. LAMOND LACKIE. 37
Br Church joined in the expression of indebtedness to Dr
Lackie for his practical and suggestive paper. He referred to
the danger of injury to the maternal parts over and about the
region of the ischial spine from pressure of the child's head
in occipito-posterior positions. Sloughing and septic troubles
might supervene from such injury. He had read Professor Sir
Halliday Croom's paper on this subject, and had been impressed
with the importance of this point. He had met with an
illustrative case in his own practice. He expressed the opinion
that in all great lying-in institutions a detailed account of
every presentation should be recorded in the case books. This
would add to their scientific value. For example, "Vertex"
was not enough. The particular vertex presentation should be
defined, and so on. In connection with occipito-posterior
positions, it would appear (from the Talmud) that the
ancient Jews were of opinion that most female children were
born in this position. Hence a medical reason for the longer
puerperium of the mother and the longer Levitical period of
ceremonial uncleanness. By kind permission, he had looked
at the books of our own Maternity Hospital and found that
there were considerably more female than male occipito-posterior
positions. Obstetricians of to-day could generalise like the
Eabbis of old, but, like them, they still found in occipito-posterior
positions possible conditions of danger and difficulty. Dr Lackie
had shown us how to lessen the difficulty.
Br Oliphant Nicholson thanked Dr Lackie for his interesting
paper, and wished to make a few remarks regarding the
management of difficult occipito-posterior labour. He had had
quite an abnormal number of such cases recently in his dis-
pensary practice, and these positions of the head seemed to be
commoner than was generally supposed. Occipito-posterior
labour might be easy or difficult ; if it was really difficult, it
constituted one of the most undesirable and dangerous complica-
tions due to malposition of the foetus — a presenting shoulder
38 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,
was infinitely more easy to deal with successfully. There were
several methods of management, in these cases, and he had
tried them all. He thought everyone who had had a large
experience in this kind of case, would agree that the manual
rotation of the child's head and body into the correct position
was the best. It was the most scientific treatment, and it was
also the best for the safety of mother and child. He would
like to mention some of the methods commonly adopted, and
briefly discuss their application to certain cases. 1. First, there
was delivery by the forceps without any attempt to correct the
position of the head. This was probably the commonest
method of all, because the general practitioner did not always
trouble to diagnose the position of the head. If a labour was
lingering, and the head did not descend, forceps were applied,
and the doctor pulled — often with his utmost strength — till the
child's head appeared at the vulva. Most of these cases were
persistent occipito-posterior ones. Sometimes rotation of the
child's head occurred during traction, especially when axis-
traction forceps were used, but generally the occiput emerged
behind. Now, even when one knew that the position of the
head was occipito-posterior, this method was sometimes good
practice. Eobert Barnes had advised it, and when the head was
relatively small, and one had not to exert dangerous traction,
the delivery was generally safely completed without extensive
perineal laceration. 2. A slight modification of this method was
gradual rotation of the head carried out by the forceps during
traction. The blades were removed and re-applied several times
till rotation was completed. This method was applicable to
those cases where the head showed indications of rotating
during traction; the application of the blades two or three
times was the important thing to complete rotation. 3. The
next method was the manual rotation of the head alone to
carry the occiput behind the pubic arch. It was then held
in its new position and forceps applied. In applying this treat-
BY DR J. LAMOND LACKIE. 39
ment it was necessary to know that the case was an occipito-
posterior one, and he had to confess — after fifteen years'
experience — that he could never be certain of this point by
means of fontanelles and sutures. In every case where the
head remained high up and would not descend, he made a very
thorough vaginal examination. With the patient well over on
her left side and under chloroform, the whole of the left hand
was passed into the vagina and the fingers pushed over the
head until an ear was felt. In occipito-posterior cases an ear
was always easily reached; that point by itself was rather
suggestive of the position. But this method he had found
excellent, inasmuch as it not only verified the position, but
indicated the direction in which one should rotate. One always
rotated away from the ear. This method of correcting the
position of the head by means of the hand was, as a rule, very
easily carried out. He always used the left hand, and the
head, being firmly grasped, was lifted up right out of the pelvis
between the pains. The manoeuvre was often carried out with
extraordinary ease; sometimes, however, it was very difficult,
and then one must adopt some other means of effecting delivery.
The main objection to this method was that, unless the body of
the child was rotated at the same time, the head had a great
tendency to spring back to its old position. Thus it was
always necessary, after rotating the head in this way, to keep
one's hand on it, and apply the forceps with the other hand.
He wished to mention the advantage, in such cases, of introduc-
ing the upper blade first ; after the application of this blade, the
head could be kept in position while the lower blade was
introduced. He might mention also the advantage of the
axis-traction forceps with straight blades — such as Milne-
Murray's — for these cases, because with them a better grip of
the head over the parietal bones was obtained; the ordinary
curved blades were certainly more apt to slip off the head
during traction. When the forceps were got on to the head in
40 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,
its new position and traction was made, the body of the child
swung round ; the neck of the child did not break. 4. The
best method of all was manual rotation of both the head and
the body of the child. The body was rotated through the
abdominal wall by placing the right hand behind the shoulder
and pressing it forwards, this being done at the same time as
the left hand in the vagina rotated the head. In some cases
this was easily done, but in others very great difficulty was
experienced in getting the body of the child round. Most
practitioners had met with these troublesome cases, and the
natural thing was to pass the hand still further into the uterus,
in order, if possible, to get the body to rotate. Last year, in an
exceptionally difficult case of this kind, Dr Nicholson, in passing
the hand higher up, came upon the child's shoulder, and grasped
it within the uterus. Then rotation was accomplished with
surprising ease. He was much impressed at the time with
this method, and he had no doubt that others who had dis-
covered the manoeuvre had been similarly impressed. On
looking up the literature of the subject, he found that it had
been described, and advocated to the exclusion of all other
methods, by Professor Mcllwraith of Toronto, in a paper
published in the Canadian Practitioner and Review of February
1905. He did not know whether others had described the
manoeuvre ; but it was certainly one that deserved to be more
widely known, and Dr Lackie had brought the matter pro-
minently before them in his excellent paper.
Dr Lackie, in reply, said that it was to him quite remarkable
how easy the children were delivered after artificial internal
rotation at the brim. In the first case he had converted an
E.O.P. into an L.O.A. ; in the second he managed to rotate the
head only to the E.O.A. position, which, however, was quite
sufficient. When it was possible, rotation of the whole child
was preferable to mere rotation of the head. He thanked the
Society for the kind way in which they had received his paper.
«
?i^» j> . .
[Tnset at page 41.
EXHIBITION OF SPECIMENS. 41
Meeting II.— December 12, 1906.
Dr N. T. Brewis, Vice-President, in the Chair.
I. The following gentlemen were elected Ordinary Fellows
of the Society :— D. Lloyd Koberts, M.D., F.K.C.P., 11 St John
Street, Manchester; J. S. Edwards, M.B., Ch.B., University
Union, Edinburgh.
II. Dr Brewis showed— (a) Two examples of endothel-
ioma of the ovary, removed from a patient aged 20. Miss
McK., admitted September 1906; complaining of swelling
in the lower abdomen and pain in that region when she turned
herself; duration two months. She had always had pain at
her periods, but since January 1906 that pain had been more
severe. She had strained herself at that time by lifting a
very heavy weight. Two months ago, when an attack of pain
had come on after turning herself in bed, she felt a hard lump
the size of a marble on the right side of her lower abdomen.
This grew gradually larger. A short time after she had
noticed the first swelling, she felt another on the left side of
the lower abdomen. This also gradually increased in size,
but she thought it was softer to the feel than that on the
right side. On admission, an irregular mass was filling the
hypogastric and lower part of the umbilical region. Menstrua-
tion regular, twenty-eight-day type; duration, seven days;
quantity fairly copious ; pain present. Operation. — Abdominal
section, double ovariotomy; small quantity of free fluid in
abdomen. Pathological Report. — Extracts from Mr Muirs
letter : — " The condition is that of lymphatic endothelioma, but is
undergoing extensive colloid degeneration. The sections from
different parts of both the right and left ovaries show that the
structure is much the same in all. The essential tissue
element is seen to be made up of endothelial cells arranged
in a very indefinite manner, but in parts one can make out
42 EXHIBITION OF SPECIMENS.
these cells to be lining lymphatic spaces, and some spaces
are filled with cells forming an alveolar-like structure. The
stroma in parts is well denned and at others scanty. The
areas showing an open network of delicate stroma forming
spaces, are really the tumour cells undergoing colloid degenera-
tion ; in parts their condition is more advanced, showing
complete transformation of the endothelial cells into colloid
material; only the stroma persists." Patient went home
feeling quite well, on the thirty-second day after operation,
having made a splendid recovery, only interrupted by a fainting
turn on the eighteenth day after operation.
(b) Bare variety of dermoid tumour, tuberculous tubes,
AND INTRALIGAMENTARY TUMOUR OF THE OTHER OVARY. Miss
B., set. 24, admitted 8th October 1906, complaining of pain
in the right side, distension of the abdomen, and occasional
pain in the left side. Duration of illness, four years ; symptoms
more marked during the last year. Menstruation regular,
twenty -eight-day type ; duration, two to three days ; flow less
in quantity since onset of pain in the right side a year ago.
On opening the abdomen a large grey- walled cyst was exposed,
and through parts of the wall of the cyst small yellow bodies
like coriander seeds could be seen floating about in the interior
of the cyst. The cyst was tapped, clear, straw-coloured fluid
and little yellow bodies escaping; the cyst was then removed
without any special difficulty. In the situation of the right
ovary was a body, yellowish in colour, and in shape and size
like a medium-sized horse-chestnut. This was adherent to the
omentum, and had to be dissected from dense adhesions to the
lower end of the caecum. The fimbriated extremity of the
right tube was attached to this body, and was swollen.
The left tube was distended in its outer third to the size of a
pigeon's egg. A round yellow body the size of a pea was
attached to the fimbriated extremity. The left ovary was
hard and cirrhotic looking. Under the left ovary and parietal
EXHIBITION OF SPECIMENS. 43
peritoneum, covering the left wall of the pelvis, was a cyst
firmly adherent to the wall of the pelvis. The patient, although
very sick and much pained for some days after the operation,
was making an uninterrupted recovery.
(c) Dermoid tumour of the ovary, which ruptured during
administration of the anaesthetic : — Miss R, age 28, admitted
2nd November 1906. Complaint. — Distension of the abdomen ;
duration, a fortnight. Some little pain in September 1906 ;
frequency of micturition at the end of October, with a little
fulness of the lower part of the abdomen. During the next
ten days the abdomen gradually became distended, till on
the day of operation it had reached the size of a six months'
pregnancy. While the anaesthetic was being administered,
the swelling disappeared, the abdomen becoming quite flat.
On opening the abdomen, greasy fluid, fat, and hair welled
up into the wound. A dermoid cyst about the size of a foetal
head was found, with a rupture in the cyst wall about 2 inches
long. This cyst, a dermoid of the left ovary, was removed.
The right ovary was slightly enlarged, and cystic. The
abdomen was thoroughly washed out, but great difficulty was
experienced in getting rid of all the fatty material. After
the operation the pulse kept very fast — over 100 — and twenty-
four hours after the operation the patient became very
restless. On the morning of the second day she was slightly
delirious. The same day a condition of stupor developed.
This gradually deepened; her pulse remained between 100
and 130 ; her respirations were at times deep, with long pauses
between, but never stertorous, and she died on the third day
after the operation. The wound was opened on the day of
her death, and there was no sign of peritonitis. The tempera-
ture the day after the operation was 99° F. ; the day before her
death it was subnormal, and remained so till just before her
death, when it rose to 102° F.
(d) Euptured ovarian tumour, presenting microscopic
44 EXHIBITION OF SPECIMENS.
characters of adenocarcinoma and tubercle : — Mrs A., age 53 ;
admitted 22nd October 1906; married twenty-eight years;
widow twelve years; six children. Complaint — Swelling on
the right side of the abdomen, with a continuous sore
feeling in that region. Patient had reached the menopause
two years before. Between that time and six months ago,
she noticed that a swelling was present on the right side
of the abdomen. This part then became tender, and had
remained so since. Six months ago a red discharge like
that at her periods set in, and lasted six weeks. Since then
this discharge had returned at irregular intervals, being
usually very copious, and sometimes had an unpleasant odour.
It was sometimes clotted. She had had pain in the right side,
and an uncomfortable bursting sensation for the past six
months. Her husband and one child died of consumption.
A large firm mass filled the left iliac, left lumbar, lower part
of umbilical, and left side of hypogastric regions. A dull note
in the flanks changed from side to side with the altered
position of the patient. Operation. — On opening the abdomen
a large quantity of free fluid escaped. The omentum was
found adherent to the tumour. The intestines were roughened,
red, and extensively studded with tubercles Ovariotomy
was performed. There was considerable bleeding and oozing.
Everything in the pelvis was very friable, and bled easily.
The left ovary was a normal senile one, and was not removed.
Pathological Report. — The tumour had the appearance of a
columnar -celled carcinoma. The specimen also consisted in
parts of granulation tissue infiltrated with leucocytes, and
presenting advanced necrosis, so that its features suggested
the probability of tuberculosis. Patient got up on the twenty-
first day after operation, having made an uninterrupted recovery,
and went home a week later, feeling and looking quite well.
(e) Uteeus with large cervical fibroid, removed at the
fifth month of pregnancy. The abdomen was opened, and the
EXHIBITION OF SPECIMENS.
45
foetus, which was not viable, was delivered by Csesarean section ;
then the uterus and large cervical fibroid which filled the pelvis
were removed by hysterectomy. (Described in paper, page 49).
(f) Uterus with fibroid tumour in lower uterine
segment, removed at term by supravaginal hysterectomy after
Ccesarean section. Mrs B., age 33. Married ten months; no
children ; no miscarriages. History. — Patient was confined to
bed from Easter Monday 1906 until May 1906 with severe
sickness. When she got up she was seized by a violent pain
in her left side, chiefly in the left iliac region. Pregnancy,
complicated by a fibroid tumour, was diagnosed. She was kept
in bed for seventeen weeks on account of the pain. A belt was
then given her to wear. She got up, and had no recurrence of
the pain. The pregnancy was allowed to go on till full time.
When labour set in, the foetal head was found occupying the
right side of the pelvis and a hard rounded swelling the left
side of the pelvis, both situated just above the brim. The
abdomen was opened, and the rounded swelling was seen to be
a rounded mass the size of a cricket ball, in the wall of the
uterus, at the left side of the lower uterine segment and under
the bladder. The child was delivered alive by Caesarean
section. The placenta was removed, and the uterus, which had
another projection from the wall at the fundus, was removed
by supravaginal hysterectomy. On section, the rounded mass
was seen to be a fibroid tumour, and the cylindrical projection
near the fundus a fibroid growth which had undergone colloid
degeneration. Both mother and child did very well, the mother
making a rapid recovery. (Described in paper, page 49).
III. Br Haig Ferguson showed — (a) 1. Tubal pregnancy
(two months), showing dilated ostium tubse, and ovum partially
protruding. Eupture had at the same time occurred slightly
into the broad ligament. Free blood in abdominal cavity;
operation on account of pain, haemorrhage, and continued
46 EXHIBITION OF SPECIMENS.
orowth of tumour. 2. Complete tubal abortion (about second
month). Tube apparently empty, but still bleeding through
open ostium. Pelvis full of clot, containing shreds of membrane
of gestation sac. Operation for pain, steadily increasing
hematocele, and symptoms of internal bleeding. In this case
it was necessary to drain through the posterior fornix into the
vagina, on account of the large raw surface behind the uterus,
which was packed with gauze. Both patients made good
recoveries.
(b) Large double pyosalpinx, apparently tubercular. The
uterus was removed at the same time, to render operation
possible. Free ends of both tubes adherent to each other
behind the uterus.
(c) Uterus with fundal cancer, removed by vaginal
hysterectomy from a nulliparous patient, aged about 55. She
complained of haemorrhage as her only symptom, and there was
no pain. Uterus measured 2 \ inches with the sound. Curettage ;
scrapings reported as malignant adenoma. Disease limited to
fundus. Satisfactory recovery. Patient had weak heart, so
the vaginal route was chosen, which, though more difficult in
a nullipara, caused less disturbance and shock to the patient.
(d) Chorion epithelioma of uterus, removed by vaginal
hysterectomy. This was the second specimen of decidnoma
malignum shown here to the Society by Dr Ferguson this year.
The patient, Mrs 0., age 38, had an imperfect abortion, and
was sent to hospital for curettage. Severe haemorrhage oc-
curred after curetting ; scrapings were examined by pathologist,
who reported chorion-epithelioma. Uterus was removed by
vaginal hysterectomy. Good recovery. Patient remaining well
four and a half months after operation. The former specimen,
which he now brought for comparison, was removed in April last,
and the patient was still in excellent health. Her age was 47.
(e) Inverted uterus, of puerperal origin, after a carefully
conducted labour. Insidious commencement, with practically
EXHIBITION OF SPECIMENS.
47
no symptoms. Eecognised six weeks after labour; reduction
impossible; vaginal hysterectomy; good recovery. (Case
reported in full in Journal of Obstetrics and Gynaecology of
British Empire, October 1906.)
(/ ) Soft subperitoneal fibroid, resembling an ovarian cyst.
This tumour was removed by abdominal hysterectomy, from
a patient aged 60. The uterus was completely upside down
in the pelvis, and was normal in size as measured by the
sound. She had been treated by pessaries for a considerable
time with no benefit. The symptoms were constant bladder
irritation, and pelvic pressure symptoms. When Dr Ferguson
saw the patient he thought the tumour alongside the uterus
was an intraligamentous cyst in close contact with the right
side of the uterus. Even after removal the examination of
the specimen gave that impression, so soft and fluctuating was
the mass. The patient made a good recovery from the operation,
and her distressful symptoms had quite disappeared.
(g) Chart showing ante-partum temperature of 105-8° F.
(malarial), when child was born alive. The patient, a primi-
para, made a good recovery, and the child did well. Labour
was to have been induced prematurely on account of a narrow
pelvis. The high temperature, however, combined with the
quinine, set the labour going just at the time the induction was
to have been done, so no further interference was necessary.
(h) Uterus, removed by vaginal hysterectomy, one year
after a double pyosalpinx (probably gonorrheal) had been
removed by abdominal section. The uterus was removed for
persistent, purulent, and offensive uterine leucorrhoea combined
with pain, which resisted curetting and all other minor treat-
ment. The patient and her doctor both urged hysterectomy,
which, owing to the shortness of the broad ligaments (the result
of the previous oophorectomy), was a somewhat difficult pro-
cedure. The uterus, when opened after removal, was found to
be transformed into an abscess cavity, with rough and sloughing
48 EXHIBITION OF SPECIMENS.
mucous surface, and containing offensive pus, penetrating down
to and involving the muscular walls. The patient's health was
completely re-established after the vaginal hysterectomy, and
she described herself as an absolutely transformed woman, as
regards her sense of well-being and comfort.
IV. Dr Barbour Simpson showed a replica of the medal
presented to Professor Pozzi last July by his colleagues, friends,
and former pupils, in recognition of his position as President
of the Seventeenth Surgical Congress, Paris, 1904, and of his
promotion to the grade of Commander of the Legion of Honour.
Dr Simpson mentioned that a Livre oVOr was also presented to
Dr Pozzi at the same time, containing twenty-four original
contributions by his colleagues, former pupils, and friends.
V. Dr Haultain showed a specimen obtained from a
multipara a fortnight ago. The history was that, when the
students arrived at the case, they were told that the placenta
had already been born. The child was born shortly after
their arrival, and the placenta came away thereafter normally.
On examination microscopically, the purplish mass of the
specimen turned out to be a blood tumour formed of capillaries
and large blood-vessels, with practically no connective tissue
between the vessels. The whitish mass was composed of
necrotic tissue. There was no trace of foetal structure or
decidual cells. The mass was about the size of a cocoa-nut, and
apparently was some abnormal product of conception analogous
to * Foetus Ovideus."
VI. Dr James Ritchie showed a specimen OF an early
ovum. The last period had taken place on 4th July; the
abortion was on 31st August ; but from the size of the ovum,
conception must have occurred only shortly before the date of
the period which was missed.
CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS. 49
VII. TWO CASES OF PREGNANCY COMPLICATED BY
FIBROID TUMOURS, TREATED BY HYSTERECTOMY.
By N. T. Bkewis, M.B., F.R.C.P.E., F.R.C.S.E., Gynaecologist, Royal
Infirmary, Edinburgh.
Cases of pregnancy complicated by fibroid tumours for which
the operation of hysterectomy is indicated are of rare occurrence.
I have previously reported to the Society two such cases : one
for fibroids obstructing the pelvis and causing severe pain, the
other for a tumour of such extremely rapid growth that it filled
the entire abdomen in three months. I now wish to add to
this record two further cases. In one the tumour filled the
pelvis, and caused such severe pressure symptoms that the
operation was a matter of urgency, and had to be performed
during the sixth month. The other was operated on at full
term, chiefly on account of the obstruction which the tumour
offered to the passage, per vias naturales, of the child. In over
1000 major operations, I have had to interfere seven times in
this manner with fibroids during pregnancy ; ovarian tumours I
have removed seven times during pregnancy ; and in cases of
malignant disease in the pregnant uterus, I have performed
Cesarean section and hysterectomy on three occasions.
In each of the cases I now wish to record, Cesarean section
preceded hysterectomy.
The first case is that of Mrs C., aged 37, who was admitted
into Ward XXXVI. in October of this year, complaining of
great pain in the lower part of the abdomen and in the back.
The patient last menstruated in the first week of June. The
early symptoms of pregnancy soon asserted themselves. In
July, trouble with micturition began — at first the act was
painful and difficult, afterwards there was increased frequency.
At this time also severe pain in the back set in, followed at a
short interval by pain in the abdomen, which confined her to
D
50 CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS,
bed, and which continued until relief was obtained by the
operation. Her menstruation began at 16, was of the twenty-
eight-day type, and lasted three days. The amount was copious
during the first day, and slight during the remaining two days.
There was always pain on the first day.
On physical examination the breasts were found to be large,
and colostrum was easily expressed from the nipple. The
abdomen was enlarged by a swelling which reached to the
umbilicus. On the right side it projected markedly, and pre-
sented the signs of a pregnant uterus. On the left there was
felt a separate swelling of much harder consistence. Per
vaginam, the finger felt this swelling passing down into the
pelvis and almost entirely filling the cavity.
The cervix was situated far forward, immediately behind
and against the symphysis pubis.
Pregnancy plus a solid tumour was diagnosed ; the patient
was anaesthetised, and an attempt made to dislodge the tumour
from the pelvis. This attempt failed however. "We were
anxious to withhold any further interference until the child
became viable, but the pain continued so severe and persistent
that it was feared some degenerative change might be taking
place in the tumour; moreover, her general condition was
becoming each day less favourable, and to add to her misery,
and to our anxiety, symptoms of intestinal obstruction and also
of ureteral pressure were beginning to manifest themselves.
It was therefore clear that we had to consider what could
best be done in the mother's interest. With this object in view
we determined to open the abdomen, deliver the child by
Cesarean section, and then proceed to remove the tumour.
A mesial incision was made from the pubis to above the
umbilicus. On opening into the abdominal cavity the gravid
uterus at once presented, and was, after some manipulation
delivered through the wound. A large fibroid tumour could
now be felt filling the pelvis. To get access to this tumour
BY DR N. T. BEE WIS.
51
it was necessary to empty the uterus. To do so, a longitudinal
incision, about 3 inches in length, was made in the anterior
uterine wall. Through this the five-and-a-half months' foetus
was delivered, the placenta was expressed, and the uterine
incision sutured. It was now possible to draw the tumour
out of the pelvic cavity, where it was found to be growing
from the posterior aspect of the supravaginal portion of
the cervix. Supravaginal hysterectomy was performed in
the usual manner. The cervical mucosa was removed; the
vaginal vault was perforated, and a gauze drain passed down
into the vagina. The abdominal incision was stitched in layers.
The patient made a most satisfactory recovery.
On section, the central portion of the tumour presented the
characteristic appearance of a fibroid, but surrounding this and
towards the surface there was extensive degeneration. The
tissues were much broken down, the spaces thus formed being
filled with glairy-like substance.
The operation just described took place on the 2nd of
November, and on the following day Case No. II. went into
labour, and a similar operation was performed on her, thus
forming a notable example of the interesting phenomenon,
which most medical men have experienced, of rare cases coming
in sequence.
The following are the chief points of interest in the
history : —
The patient, 33 years of age, has been ten months married.
There is no history of any previous pregnancy or abortions.
Menstruation began at 13, was regular, lasted five days,
and, until two years ago, presented no abnormalities. For
the past two years there has been a dull dragging pain, chiefly
in the iliac regions and upper parts of the thighs, during the
menstrual period. There has never been any intermenstrual
discharge. For some time there has been increased frequency
52 CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS,
of micturition, but neither pain nor difficulty. Albumen was
present in the urine.
Patient last menstruated from the 7th to 12th February
1906. In the latter part of April 1906 patient had severe
sickness, and was confined to bed for two or three weeks. On
getting up she experienced severe pain in the left side. This
was at times agonising in its severity, and was most marked in
the left iliac region. The pain persisted for three or four weeks,
and then gradually became less severe. When the pain had
subsided, the patient was examined by her doctor, who told her
she was pregnant, and also that she had a tumour ; he kept her
confined to bed for seventeen weeks. I saw her in consulta-
tion at the end of August 1906, when I found her six months
pregnant. Growing from the left side of the uterus there was
a hard tumour, which filled the greater part of the pelvic brim.
The patient was most anxious to have a living child, and,
as the symptoms were now not so severe as they had been,
we decided not to interfere until the full term. I ordered the
patient an abdominal belt, and advised her not to remain
in bed. The support obtained from the belt had the desired
effect : there was no recurrence of the abdominal pain.
The patient came into my Home on 27th October, and
subsequent to that date was under my personal observation.
On 3rd November she complained of pain all day at intervals ;
this was felt chiefly in the back, and did not tend to radiate
to the front. At 4 p.m. the membranes ruptured. At 6 p.m.
the cervix, on vaginal examination, was found to be soft, but
only sufficiently dilated to admit the tip of the index finger.
The foetal head was found on the right side of the abdomen,
above the pelvic brim. On the left side, also just above the
brim, there was a firm rounded mass, about the size of a foetal
head. Attached to the uterine wall, about 2 inches above
and to the left of the umbilicus, there was a projection which,
through the abdominal walls, felt like a foetal foot and leg.
BY DR N. T. BREWIS. 53
At 7 p.m. the patient was anaesthetised and a thorough
examination made. The head was found -still above the brim,
which it was prevented from entering by the tumour. The
cervix was still undilated. As the liquor amnii had drained
away some hours before, and the child had consequently been
exposed to severe pressure between the fibroid and the strongly
acting uterus, it was decided that labour should, alike in the
interests of mother and child, be terminated as quickly as
possible. The safest method for both was undoubtedly Csesarean
section.
The abdominal cavity was opened by an incision extending
2 inches above the umbilicus. The uterus was brought into the
wound. The obstructing tumour was found to be a fibroid
situated on the left side of the lower uterine segment ; it was
rounded in shape and about the size of a cricket ball. The
projection from the body of the uterus, described above, was
found to be an irregularly shaped subperitoneal fibroid situated
about lh, inches internal to the insertion of the left round
ligament. The bladder had markedly hypertrophied walls and
was found to reach to an abnormally high level.
The uterus was opened by an incision about 4 inches long
in the anterior wall. Through this the child was delivered and
the placenta removed. The uterine incision was then sutured
with thick catgut. The tumour was next shelled out of the
uterine wall. In spite of all efforts to promote uterine action,
the organ remained in a relaxed, flabby condition. Owing to its
atonic state and the consequent oozing, it was found necessary
to perform supravaginal hysterectomy.
The child, though small, was in no way malformed.
Mother and child returned home well twenty-eight days
after operation.
Remarks. — The presence of fibroid tumours in the uterus
may complicate pregnancy, parturition, and the puerperium in
54 CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS,
a variety of ways. The site which the growth occupies is the
chief factor in determining the significance of the complication.
For example, subperitoneal growths in the body of the uterus,
unless of considerable size, may not give rise to any symptoms
during pregnancy, and may not interfere with the progress of
parturition ; while a tumour growing in the lower pole of the
uterus may give rise to severe pressure symptoms during
pregnancy, and may constitute a complete barrier to the passage
of the f oetus through the pelvis during labour. An intra-uterine
growth may interfere with the development of the product of
conception and lead to abortion, with risks of haemorrhage and
sepsis, or may hinder delivery, or cause post-partum haemorrhage.
Therefore pregnancy may occur in a uterus the seat of a fibroid ;
but such a tumour may cause no symptoms during pregnancy,
and need cause no anxiety. Here we may leave nature to
safely terminate the labour. On the other hand, a fibroid
tumour may so complicate a pregnancy that not only are the
symptoms during pregnancy urgent and severe, but its presence
may place the patient's life in jeopardy when labour sets in.
The cases which I have just related belong to this class. The
first was an example of a tumour causing distress and danger
during pregnancy, the second was an example of a tumour caus-
ing danger during labour. When it is clear that a pregnancy,
complicated by fibroid tumour, requires surgical treatment, it
is possible that the case may be treated, and scientifically
treated, by more methods than one, though, doubtless, there
must in each case be one method better than any other. In my
opinion, this applies to Case No. II., but not to Case No. I.
The propriety of the treatment adopted in Case No. I. could
not be questioned. The tumour filled the pelvis, and could not
be dislodged ; it presented an impassable barrier to the transit
of the child; its presence was a menace to life, and caused
symptoms which could no longer be endured by the patient.
The indications were so urgent, there was no alternative but to
BY DR N. T. BREWIS. 55
operate without delay in the interests of the mother. The
only method other than the one adopted would have been to
remove the tumour, leave the uterus, and thus give the mother
a chance of carrying the foetus to term. This did not occur to
me at the time, but an examination of the specimen shows that
such a method, however ideal, was in this case impracticable.
In Case No. II., the tumour gave rise to no urgent symptoms
during pregnancy, and in this case our treatment was to be
planned and carried out with the view of saving both
mother and child, or, better still, mother, child, and uterus.
The possible procedures that occur to me other than the one
carried out are two in number : —
1. Labour might have been induced at the seventh
month and the tumour removed subsequently. Against this
plan we have to consider the risk of the induction to the
mother, the risk of losing the child, and the subsequent major
operation for removal of the tumour.
2. The tumour might have been removed without interfering
with the pregnancy. This might have been attempted, but
there were not sufficient grounds to ensure the successful
carrying out of this procedure.
As events turned out, this result would not have been
attained without difficulty and danger. The tumour was placed
under the bladder, was sessile, and had a broad attachment to a
very vascular part of the uterus, and haemostasis would have
been difficult and uncertain. The question of whether the
fibroid uterus should be sacrificed after removal of the child
and the tumour was considered, and decided in the affirmative :
first, on account of the uncertainty of being able to deal satis-
factorily with the bed from which the tumour had been
removed ; and secondly, from the fact that the remainder of the
body of the uterus was not healthy. I think, as events proved,
the course which we followed was right and proper. The
mother and a healthy child were saved, and the former returned
56 CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS.
home well and strong ; and, though deprived of the power of
bearing offspring in the future, I think that, after her experience,
she will be glad that such an event is not possible.
Dr James Ritchie said they were very much indebted to
Dr Brewis for having submitted these two very interesting
cases. The class of case referred to was one of extreme gravity
in practice. When one discovered a cervical tumour in a
married woman, it was often a matter of great difficulty to know
how to treat the case. Although the tumour might not be very
large at the beginning of pregnancy, it would probably grow
very much during pregnancy. Should immediate operation be
recommended, or waiting? He thought Dr Brewis had put
before them very clearly the rules for guidance in such cases.
It would, he thought, be well to explain to the patient the
greater danger of waiting for operation till full term rather than
having it dealt with at a comparatively early stage of preg-
nancy; and, having given the explanation, to allow the patient
to choose between early operation and waiting events. In the
first case there was no doubt about the procedure which
should be adopted.
Dr Lamond Lachie thanked Dr Brewis for the report of
two such interesting cases. He said it was quite clear that Dr
Brewis had adopted the best possible means of saving those
patients, but remarked that it was curious how in some cases
nature so frequently seemed to overcome difficulties that at first
sight seemed insuperable. The most interesting case he had
seen of pregnancy complicated by fibroid tumour was of a lady
who had come to Edinburgh on account of a fibroid tumour com-
plicating pregnancy, diagnosed by her doctor. Dr Lackie in
examining per vaginam had found it absolutely impossible to
feel any os. The pouch of Douglas was entirely occupied by
PKOGNOSIS OF PKEGNANCY IN PATIENTS WITH ONE KIDNEY. 57
the fibroid. It was determined to leave the patient for a time,
and perform Cesarean section at a later date. At eight months
labour set in, and at once preparation was made for Cesarean
section. Labour went on very rapidly, and on examination it
was found that the cervix had descended, and the os was lying
practically in the centre of the pelvis, so that the fibroid tumour
which had occupied the pouch of Douglas had risen up, and
the head of the child presented in the normal way. After the
birth of the child the os had ascended again, and the pouch of
Douglas was again occupied by the tumour, and it was found
necessary to give chloroform and hook the cervix down, pass in
the hand, and remove the placenta. The patient made a good
recovery, and went home with the tumour very much less in
size than it had been during pregnancy.
Dr Keppie Pater son asked if Dr Lackie had followed up the
case, but Dr Lackie replied that he had not done so.
Dr Brewis, in reply, said the case cited by Dr Lackie might
have been a pedunculated fibroid.
VIII. ON THE PROGNOSIS OF PREGNANCY IN
PATIENTS WITH ONE KIDNEY, WITH NOTES OF
AN UNUSUALLY COMPLICATED CASE OF LABOUR
AFTER NEPHRECTOMY.
By James Haig Ferguson., M.D., F.R.C.P.E., F.R.C.S.E., F.R.S.E. ;
Assistant Gynaecologist, Royal Infirmary, Edinburgh; Assistant
Physician, Royal Maternity Hospital, Edinburgh j and Gynaecologist,
Leith Hospital.
In recent years, owing to the brilliant and rapid advances of
surgery, the operation of nephrectomy has become no uncommon
procedure for various diseased conditions of the kidney. It
follows that we as obstetricians will occasionally be confronted
with the question : Should a woman with one kidney be advised
58 PROGNOSIS OF PREGNANCY IN PATIENTS WITH ONE KIDNEY,
to marry and run the risk of becoming a mother? I am
assuming, of course, that the remaining kidney is healthy and
equal to its duties in ordinary circumstances.
We know that during pregnancy in healthy women the
kidneys undergo hypertrophic changes of a strictly physiological
character, so as to enable them to cope with the increased work
they have to do. In the same way, as is well known, the one
healthy kidney in the patient whose diseased kidney has been
removed undergoes hypertrophy, which probably began long
before the nephrectomy was performed, the diseased kidney
having in all likelihood been more or less functionless for a
considerable time prior to operation.1 If in such a case
pregnancy should then supervene, further hypertrophy will be
required to meet the necessary demands; and as, so to speak, all
the patient's eggs are now in one basket, any undue strain on
this kidney will at once mean very serious renal insufficiency.
The case I am about to record shows that in a patient
whose remaining kidney is healthy, and has had time to become
sufficiently hypertrophied to perform the work of two, the
strain of pregnancy can be fairly well borne ; for although the
patient developed albuminuria, and had a diminished excretion
of urea, yet when she was put on proper treatment (though it
was somewhat late in the day) the condition yielded fairly
satisfactorily to appropriate remedies, and the kidney irritation
tended to subside. In fact, this patient with only one kidney
had, on the whole, less severe albuminuria and less toxic dis-
turbance than many albuminuric primigravidse both of whose
kidneys are known to be organically sound, though it is possible,
and indeed probable, that in my patient's case the amount and
1 In one case recorded in the discussion on Mr Twynam's paper on
nephrectomy in pregnancy {Lancet, vol. i., 1898, p. 165), it is stated that
after removal of one kidney in a man, for laceration, where all the work
was thrown suddenly on the opposite organ, the amount of urine and
urea became normal in four days' time.
BY DK JAMES HAIG FERGUSON.
59
virulence of the toxin or toxins she was manufacturing were
comparatively insignificant. It is manifestly impossible to
institute comparisons between different patients on this point.
The only other instance of which I have personally known
where pregnancy occurred in a patient with one kidney, was in
the case of a lady who was married about two years ago, after
having had nephrectomy performed. Pregnancy shortly super-
vened, and she died, I understand, of eclampsia shortly after a
premature labour.
One would, on the whole, I think, prefer, so far as one's
limited knowledge goes, that patients who only possess one
kidney, even though it is apparently a healthy one, should, if
they marry at all, delay marriage till after the menopause.
One could not, however, give such uncompromising advice ; it
would be impracticable, and indeed in many cases hardly
justifiable, besides being highly unwelcome to many of the
recipients. Each case would require to be judged on its own
merits, and after a careful consideration of all the attendant
circumstances. Some patients might be determined to take a
certain extra risk for reasons all-important to themselves, and
such are apt to listen to no arguments which in any way run
counter to their own views and inclinations. I should be
strongly inclined to urge, in the interests of prudence, that
marriage be delayed till at least three years from the operation
of nephrectomy, so as to give the remaining healthy kidney
ample time for compensatory changes to occur under the
influences of the varying vicissitudes of ordinary life — in fact
to establish and consolidate a condition of matters which will
enable the one kidney safely and easily to do the work usually
undertaken by two.
Of course if the remaining kidney were diseased, marriage,
where there is any possibility of child-bearing, should, in my
opinion, be out of the question.
Whenever a first pregnancy occurs in a patient with only
60 PROGNOSIS OF PREGNANCY IN PATIENTS WITH ONE KIDNEY,
one kidney, she should be most carefully watched, and placed
in circumstances where this watching can be thoroughly and
systematically carried out, her urine being examined and tested
regularly during the whole duration of pregnancy, with the
view of immediately bringing the pregnancy to an end should
she show any evidences of renal inadequacy which fail to
respond to general treatment.
Special care should be taken to ensure that the excretion of
urea is not diminished, and in this connection it is well to
remember that the excretion of urea in healthy pregnant
women seems to be considerably less than is usually supposed,
varying, according to Whitridge Williams, from 20 to 24
grammes in the twenty-four hours. I have certainly in some
cases verified this observation, but was inclined to put it down
to commencing failure of excretion, and diminishing power in
the kidney function, in fact to commencing toxaemia. Be this
as it may, there can be no doubt, as Marx has shown, that urea
is always diminished in the toxaemia of pregnancy, and that
this diminution is a much more valuable, and certainly an
earlier indication, than either the presence of albumen or casts,
both of which latter may be absent even in bad cases. If this
were more generally recognised and acted on, there would, I
feel sure, be fewer cases of eclampsia than we now have to
deplore.
The same general principles would hold, as regards sub-
sequent pregnancies, in the case of a parous woman who had
been the subject of nephrectomy, always bearing in mind the
fact that primigravidae are more specially liable to the toxaemic
disturbances which may be associated with pregnancy.
The same remarks might be applied in the case of a woman
with one kidney f unctionless, as, for example, in hydronephrosis,
or where only one kidney is diseased and the other healthy, as
proved by Luy's separator or by catheterising the ureters. In
such cases of kidney disease it would be of great importance to
BY DR JAMES HAIG FERGUSON. 61
discover the exact condition of each kidney, for in my opinion
the prognosis as regards the supervention of pregnancy would
be worse with two kidneys even slightly diseased, than where
only one kidney is diseased (even considerably so) and the
other healthy. The advantage one has in the case of the woman
with only one kidney is that one knows exactly where one is as
regards the condition of the remaining kidney, and can speak
therefore with a more certain voice as regards probabilities and
possibilities.
I have been unable to find much information in literature
on this subject. There is a considerable number of cases
recorded where, on account of urgent kidney complications,
nephrectomy had to be performed during the actual existence
of pregnancy, in many cases with satisfactory results both as
regards the mother, the continuance of the pregnancy, and the
health of the child.
Fritsch says that pregnancy can be carried through with
nephrectomy of one side, and quotes a case of Bovee's in
support of this. He says, however, that the remaining kidney,
if it becomes in a higher degree a "pregnancy kidney," may
easily become insufficient, and that this may lead at once to
the most serious eclampsia. Schramm, quoted by Cumston,
records a case where the right kidney had been removed and
pregnancy and labour were practically normal. He sums up
by saying that a patient having but one kidney may go through
pregnancy and labour without any injury to her health, but it
is probable that such a patient would have diminished resisting
power should she be afflicted with chronic nephritis, and that
an attack of eclampsia would be fatal to her. In other words,
with good fortune, she may pass through her pregnancy and
labour safely, but any breakdown will necessarily tend to be
greater, and therefore apt to be more disastrous.
The variety of the complications which had to be dealt with
in the following case was greater than I have ever before met
62 PROGNOSIS OF PREGNANCY IN PATIENTS WITH ONE KIDNEY,
with in any one patient, and the cases must be few in which so
many obstetrical difficulties have been concentrated in one
individual. For in addition to the fact that she had, some
years previously, undergone the operation of nephrectomy, the
patient was the subject of albuminuria, and had besides a
contracted pelvis, placenta prsevia, and a cervical polypus,
whilst, in the way of obstetric operations, induction of labour
and craniotomy were required, and manual removal of an
adherent placenta was necessary, in order to complete the third
stage.
The notes of the case are as follows : —
F. K, aet. 36, a primigravida, was admitted to the Edinburgh
Maternity Hospital at 9.30 p.m., on the 29th December of 1905.
The patient had last menstruated on the 20th of March
1905, and on admission it was noted that in spite of the fact of
her being a primigravida, and in the last month of gestation,
the foetal head was not engaged in the pelvis, but was freely
movable above the pelvic brim. The foetus lay in the left
occipito-anterior position.
The patient stated that she was quite well during her
pregnancy till the end of October 1905, when her legs became
so much swollen that she had to go to bed, where she remained
for a week. She had been liable to occasional severe head-
aches.
On 28th December, the day before her admission to hospital,
she was suddenly seized with severe headache, and flashes of
light before her eyes, but she noticed no swelling of hands or
face. On admission, her urine, which was scanty, contained 2
grains of albumen and 4 grains of urea per fluid ounce. She
was thin and very pale, and there was considerable dropsy of
the lower limbs, of the abdominal wall, and of the vulva.
When five years of age she had had scarlet fever, followed
by nephritis. In February 1896, her left kidney was removed
for tuberculous disease. The symptoms which led up to the
BY DR JAMES HAIG FERGUSON. 63
nephrectomy and which had lasted for twelve months before
the operation, were progressive emaciation, blood in the urine,
frequency of micturition, night-sweats, and attacks of severe
pain in the left lumbar region. She states that she recovered
well from the operation, but that the wound did not heal for
twelve months afterwards. Since then she has remained well.
She has now no pain or discomfort on micturition, but passes
water rather frequently — every two hours or so.
Menstruation began when she was 16. years of age, and
recurs at intervals of twenty-four days. It is fairly profuse.
She has no dysmenorrhoea or intermenstrual discharge.
Examination of the pelvis showed an intercristal diameter
of 10 \ inches, and an interspinous diameter of 8f inches. The
diagonal conjugate was fairly normal, just slightly under 4J
inches. The pelvis was, however, much contracted transversely,
and was of a kyphotic type.
The patient's general condition improved under milk diet
and complete rest in bed. Her urine increased in quantity
up to 50 to 60 fluid ounces per diem. The urea varied from
2 J to 4 grains per fluid ounce, and the albumen decreased
to 0*4 grains per fluid, ounce.
In view mainly of the head not having entered the pelvis,
it was decided to induce labour, as there seemed some hope
of getting the head through if it were not too firmly ossified.
Accordingly a bougie was introduced into the uterus on the
evening of 3rd January 1906. There was some bleeding
per vaginam after this, and this was at the time attributed
to a small polypus which projected inwards from the left side
of the cervical canal. There were occasional transient pains
during the next twelve hours, and at the same time some
further bleeding, not severe, but more than seemed to be
accounted for by the cervical polypus. On careful examina-
tion after the os became patent, there was found to be a
lateral placenta praevia, with apparently a somewhat shrivelled
64 PROGNOSIS OF PREGNANCY IN PATIENTS WITH ONE KIDNEY,
placental lobe. The pains almost disappeared during the next
twenty-four hours (even though the membranes had ruptured
prematurely), and there was not much haemorrhage. On the
morning of 5th January 1906, a Champetier de Eibes's
bag was inserted through the os, which was about the size
of a florin and very rigid. Strong pains came on during the
day, and at 3 P.M. the patient was looking and feeling very
much worn out, her pulse being 118 to the minute. At
3.30 p.m. she was anaesthetised, the Champetier's bag was pulled
slowly down, so as to fully dilate the cervix, as well as to
stretch the vagina and perinaeum, the forceps was applied
to the foetal head, and every effort was made to effect delivery
in this way. All such attempts, however, proved futile,
as the head was too large and too firmly ossified to pass through
the pelvic brim. I therefore performed craniotomy, and the
child was even then with difficulty extracted, as both the
cavity and outlet of the pelvis were likewise transversely
contracted. The child was delivered at 4.25 p.m., it was a
male, weighing 5 lbs. 13 oz., and was 22 inches in length.
The placenta was retained, and after half an hour I inserted
my hand into the uterus, found it completely adherent, and
verified the diagnosis of partial placenta praevia. After
manually detaching and removing the placenta, an intra-
uterine douche was given, and it was found necessary to insert
three stitches into the perineum The placenta showed a
shrivelled lobe.
The puerperium was uneventful. The albumen steadily
diminished and ultimately entirely disappeared, and the
patient was discharged well on the twelfth day.
This case is mainly of interest from the fact of the patient
having only one kidney with which to face the strain of her
first pregnancy and labour. Clearly, labour should have
been induced at a much earlier date in order to have been
of any service in giving the child a chance of life, but unfortu-
BY DR JAMES IIAIG FERGUSON. 65
nately the patient did not come under observation until too
late for this operation to have been of any real advantage
in the child's interests, and it was done therefore more for the
mother's sake than from any great hope of saving the child.
It is to be noted that the patient had a history of nephritis
after scarlet fever in childhood, from which she seems com-
pletely to have recovered, at least in so far as the right kidney
was concerned. Her left kidney was removed for tuberculous
disease in 1896, nearly ten years before her confinement, so
that during all these years she had manifestly been entirely
dependent on the right kidney for all her renal functions.
Fortunately this kidney proved to be healthy, and rose to
the occasion most satisfactorily. But if it was equal to the
work required of it in the non-gravid state, the strain implied
by the occurrence of pregnancy and labour, and the increased
functional activity necessarily produced thereby, set up a
condition of relative insufficiency, which fortunately, however,
did not go the length of a complete breakdown. Had the
pregnancy chanced to have been multiple, or had the toxaemia
been greater, one could hardly have hoped for a favourable
result.
Eeferences.
In the Handbuch der Geburtshiilfe, by von Winckel (Wiesbaden,
1904), Zweiter Band, ii. Teil, page 1432, practically all
the references to kidney operations during pregnancy
are given. The reference to Twynam's case is given
erroneously under " Frymann."
Also, "Pregnancy and Labour following Nephrectomy," by
Baldwin, Cleveland Medical Journal, 1903, ii., p. 213.
Dr Brewis said he had listened with pleasure to the most
interesting paper from Dr Haig Ferguson, and thanked him for
bringing the case before the Society. Dr Ferguson had referred
E
66 PROGNOSIS OF PREGNANCY IN PATIENTS WITH ONE KIDNEY.
to the scarcity of instances of pregnancy occurring in the case
of a patient with only one kidney. He had looked over his
records and found that in April 1896 he had removed the right
kidney from a Mrs B., and that in August 1898 Mrs B. had a
child. He was told that there was no complication at all in the
labour, and that the patient was still quite well.
Dr James Ritchie said they had listened to a very interest-
ing paper. When asked to attend a lady, he advised her to
inform him should increased frequency of micturition occur,
or if there was too small a quantity of urine, or if there
was any swelling of the limbs. If the patient was otherwise
healthy, he did not make further examination. If the patient
were known to have an abnormal condition of the urine, it
was one's duty to have the urine frequently examined during
the whole time of pregnancy; if the patient be known to have
only one kidney, one should make perfectly sure that that
kidney was acting well by examining as to quantity of urine
passed, its specific gravity, and the amount of urea.
Dr Fred. Porter asked Dr Haig Ferguson why in the
management of the case of labour, having diagnosed a contracted
pelvis and partial placenta praevia, turning had not been
attempted With regard to albuminuria and one kidney only,
and Dr Ferguson's advice for the woman not to marry till the
menopause, he considered the advice rather hard, and until one
knew what albuminuria and eclampsia were really due to, he
would not advise non -marriage. He had had an experience of a
lady who had become pregnant after nephrectomy, and though
the case had not been under his care, he knew that she had a
child two years after the nephrectomy, and that it was an
absolutely simple labour, and the child was still living
Dr Haig Ferguson, in reply, said that he did not say he
advised a woman not to marry under such circumstances. As
to the treatment carried out, the placenta prsevia was not
diagnosed till the membranes had ruptured, and it was a \ery
SUCCESSFUL TREATMENT OF PUERPERAL FEVER. 67
partial placenta prsevia; the lobe presenting was somewhat con-
tracted. Further, one could not have turned well in a kyphotic
pelvis with a narrow outlet. Even if the condition had been
recognised earlier, he did not know that he would have con-
sidered version as at all a practical procedure in the circum-
stances.
IX. SUCCESSFUL TREATMENT OF PUERPERAL FEVER
BY ANTISTREPTOCOCCIC SERUM.
(Abstract.)
By Dr Garnet Leary (Communicated by the Secretary).
In this communication the author gives his experience of anti-
streptococcic serum in the treatment of cases of puerperal sepsis
occurring during 1900-1902 in an extensive club and mixed-class
practice Eecovery took place in all the cases, this successful
result being ascribed to the combined and persistent use of in-
tra-uterine douches along with the administration of the serum.
At the onset of symptoms of infection intra-uterine douches
of corrosive (1 in 1000) or creoline (51 to pint) were generally
given twice or three times daily, carbolic (1 in 40) being
substituted after a few days. In cases where, after the lapse
of two or three days, no improvement took place in pulse and
temperature, and whenever the temperature rose to 103° F. to
104° F., and pulse to 120, curettage by a blunt instrument was
performed, and fresh antistreptococcic serum employed and
repeated frequently, according to the severity of the symptoms.
Opportunities for making microscopical examination or
taking cultures were not available; but the occurrence of
rigors, high fever, rapid pulse, sweats, diarrhoea, and marked
wasting distinguished most of the cases as of true streptococcic
origin. In a smaller number of cases the symptoms, while
alarming, were less severe, and yielded to intra-uterine douching.
In these the infection was probably saprophytic.
68 SUCCESSFUL TREATMENT OF PUERPERAL FEVER BY
The following cases are detailed, viz. : —
Case I. — Multipara, set. 32, with previous history of heart-
disease, was seized with haemorrhage at sixth month of preg-
nancy, and when seen some hours later was collapsed, with
almost imperceptible pulse. The os was dilated to the size
of -a florin. Pains being weak and hemorrhage continuing, a
diagnosis of accidental haemorrhage was made, dilatation com-
pleted by the fingers, and a six months' foetus was delivered by
forceps. The placenta was stripped from the uterine wall, the
uterus irrigated with creoline and corrosive, and the patient
freely stimulated. As collapse continued, saline injections were
given, foot of bed raised, legs bandaged, etc. After remaining
semi- comatose for twenty hours, she rallied slowly to the fourth
day, temperature keeping 99° F. to 100° F. On the fourth day
the temperature rose with a rigor to 105° F., pulse 168 and
thready, and she appeared to be sinking. Cold sponging and
administration of quinine and phenacetin causing only slight
temporary improvement, 10 c.c. antistreptococcic serum were
injected into the abdominal muscles. This was followed at first
by another rigor and rise of temperature, but in six to ten hours
temperature fell to 102° F., and pulse was stronger and 152.
Another injection was given and followed by another rise in
temperature to 104° F., and a third injection twelve hours later.
Next day temperature was 100° F., pulse 140, and patient
showed much general improvement, becoming for the first time
able to mutter a few words and to recognise those around her.
Improvement was gradual and steady from this point, and
patient was able to leave her bedroom in two months. After
a few months further treatment for her heart lesion, she was
in better health than she had been for years.
Case II. — Multipara, set. 28, was seized with profuse
haemorrhage at the eighth month. The os was dilated to the
size of a crown piece, but pains were few and feeble, and as
ANTISTREPTOCOCCIC SERUM, BY DR GARNET LEARY. 69
haemorrhage continued profuse and edge of placenta could be
felt presenting, the membranes were artificially ruptured,
turning effected, and the uterus plugged by traction on the
foetal legs. After saline injections and stimulants had been
given to combat the profound collapse, delivery of a dead foetus
was accomplished. The placenta, which was adherent, was
then removed piecemeal with difficulty, and the uterus curetted
and douched. Collapse was again profound, but patient rallied
in a few hours, and made satisfactory progress until the third
day, when septic symptoms supervened, with rapid pulse, pain,
and distension of abdomen, accompanied by offensive discharge.
These symptoms continued, in spite of douching twice daily,
until the sixth day, when temperature, which had been 101° F.
to 103° F., rose with rigor to 105° F., pulse 140. Intra-uterine
douching was continued, cold sponging done, and quinine
sulphate, phenacetin, and sodium salicylate given internally,
with improvement for some hours, but as temperature again
rose to 104° F., 10 c.c. of serum was injected. Ten hours later
temperature fell to 100-5° F., pulse 120; patient began to take
food, and looked better. Serum was repeated next morning.
For two days temperature remained between 100° F. and 102-5°
F., pulse 100 to 120, intra-uterine douching being continued.
A third injection was then given. The symptoms became
greatly improved, but further complications supervened in the
form of pelvic peritonitis with abscess in the pouch of Douglas
and a mammary abscess. The administration of the serum
on several occasions at this stage seemed to give beneficial
results, the abscesses being also incised and drained. A
threatening abscess, in the other breast seemed to be aborted
by a timely injection. Kecovery was then rapid, and patient
left her bed some three weeks later, but a few days afterwards
developed phlegmasia alba dolens, from which she made a good
recovery after six weeks treatment: was able to resume her
work in a factory, and enjoyed good subsequent health.
70 SUCCESSFUL TREATMENT OF PUERPERAL FEVER BY
Case III. — Mrs C, primipara, was delivered by forceps of
a large full-time child with difficulty because of hip-disease
and slight pelvic deformity. The perineum was torn badly, and
stitched, but did not heal well. On third day lochia were
offensive ; temperature 99 '5° F., pulse 104. Intra -uterine douches
were given twice daily, stitches removed, and edges of wound
purified. At the end of a week, during which temperature kept
from 100° F. to 102° F. and pulse 100 to 130, patient had a rigor,
and gave much trouble with noisy delirium. During the next
few days serum was injected four or five times, each dose being
followed in five or six hours by marked improvement. The
temperature came down to 99° F., pulse 108, and she became
quiet and rational, and took more nourishment. Improvement
was steady for three weeks, when, after being up, abscesses
developed in both mammae, and slight phlegmasia alba dolens
came on in left leg. Serum was used for both conditions, and
appeared to markedly ameliorate the symptoms. In six weeks
she was quite well, and able for her household duties. It was
subsequently ascertained that the midwife in attendance on
this patient had come to her from attendance on a fatal case of
puerperal septicaemia.
Case IV. — Mrs O., multipara, was delivered by forceps for
tedious labour, a small perineal tear being stitched. The
perineum suppurated, and on fourth day temperature rose to
100° F., pulse 108, and an offensive discharge was present. In
spite of douching, temperature and pulse continued to rise, and
on sixth day curettage was done. This was followed on eighth
day by a rigor, and patient became semi-comatose for several
hours. A serum injection reduced temperature to 101° F.,
pulse 115. Next day another rigor occurred, with collapse and
unconsciousness for nearly twelve hours. Patient was freely
stimulated, and two more injections of serum were given. Next
day temperature was 100° F., pulse 110, and general condition
ANTISTREPTOCOCCIC SERUM, BY DR GARNET LEARY.
71
quiet and reasoning. She continued to make a remarkable
recovery, and was able to get about at the end of the third
week.
As Cases II., III., and IV. occurred in succession, at a
few weeks interval, the author suggests that the midwifery bag
may have been instrumental in transmitting the infection,
which view was strengthened by the cessation of the series
after thorough sterlisation of the bag and its contents.
Case V. occurred in the practice of Dr T. Leary, J.P., father
of the author, in 1902. Mrs S., set. 20, was delivered by
forceps, the perineum being slightly torn, but not requiring
stitching. The patient progressed normally until the fourth
day, when temperature rose to 101° F., pulse 110. Next day a
slight rigor occurred, accompanied by vertigo, restlessness, and
some delirium. There was tenderness in the left iliac region,
and diminished lochia and milk secretion. Douching twice
daily with corrosive sublimate was carried out up to seventh
day, when temperature, which had hitherto kept about 101° F.
to 102-5° F., rose to 104° F., with marked exaggeration of the
previous symptoms. The pain over the uterus was so severe
as to necessitate morphia suppositories. Pulse was 140, of good
volume, and regular. At night patient became prostrate and
semi-comatose, and showed tremors and twitchings. As patient
seemed worse next morning, antistreptococcic serum was tried,
on the suggestion of the author. The improvement by the
following morning was remarkable, and temperature had fallen
to 100° F., pulse 116. The same evening another injection was
given, with equally satisfactory result, the temperature falling
the following day to 99-5° F., and the diarrhoea, which had been
intractable for days, ceased. Four days later a relapse, with rise
of temperature to 102° F., pulse 100, and recurrence of pain,
flushing, and diarrhoea, yielded promptly to other two serum
72 SUCCESSFUL TREATMENT OF PUERPERAL FEVER BY
injections. Progress after that was uninterrupted, and patient
was able to resume her household duties ten days later. On
searching for the cause in this case, the fact was elicited that a
lodger in an adjoining room was suffering from erysipelas. In
this case, which was therefore in all probability a pure strepto-
coccus infection, the serum seemed to have a more directly
beneficial effect than in the other cases. This result may also
have been due to the more frequent repetition of the dose, as
three serum injections were given within twenty-four hours
and two the following day.
General Remarks and Conclusions. — In none of the cases did
metastatic abscesses occur as the result of the use of the serum,
nor was any local suppuration met with. The serum used was
always fresh, and both Burroughs Wellcome's and Parke Davis's
preparations were used.
After referring to the diversity of organisms that may give
rise to septic conditions after labour, including different varieties
of the streptococcus, Loeffler's bacillus, and bacillus coli, either
in pure or mixed infections, as accounting in some degree for
the apparently contradictory clinical results in cases where
serum has been employed, Dr Leary summarises his conclusions
as follows : —
1. The serum should be used in all cases which do not give
way rapidly under treatment by douching, drugs, etc.
2. A bacteriological examination should, if possible, be made
from the cervical and vaginal discharge.
3. Frequent repetitions of the serum should be given, de-
pending on the severity of the case, especially noting the pulse.
4. Treatment of all complications that may arise should
include use of the serum.
Dr Keppie Paterson said it was a very interesting paper to
which they had listened. He said he had himself used serum
ANTISTREPTOCOCCIC SERUM, BY DR GARNET LEARY. 73
in two of his cases without any evident benefit — in one case
several injections had been given. He felt that the injection of
serum in test cases of fever in the puerperium was very much
empirical until one could make sure what germ they had to
deal with. In one of his cases he had obtained a blood culture,
and bacillus subtilis was the germ found. It was really
necessary to obtain a culture from the secretion within the
uterus and from the blood in these cases. Then one might
hope to benefit the patients by the use of the particular serum.
Dr Lamond Lackie considered that an intra-uterine douche of
1 in 1000 corrosive was too strong to be used. The curettage also
was not a very satisfactory treatment, for there was great risk of
opening up new channels of infection. As to his present experi-
ence of the use of antistreptococcic serum, it had been eminently
unsatisfactory. Any success that had been obtained in any
case, he thought, might quite well have been due to the local
treatment — the careful washing out of the uterus with saline
or sterilised water. The difficulty was to know exactly what
the sepsis was due to. To overcome this difficulty, a polyvalent
serum had to be introduced, made from various species of
streptococcus, and that form of serum was supposed to be more
able to counteract the poison. But it seemed to him that one
would need to use an enormous dose of the serum in order to
give the antidote of the particular streptococcus present. In
sapremia the serum was practically useless, but with local
treatment one obtained satisfactory results. In real cases of
septicaemia one would like to have a serum, but serum had had
no effect in his experience. A Committee in New York had
come to the conclusion that the serum was absolutely worthless
in these cases. In cases in which good appeared to have been
obtained, it seemed difficult to know exactly what had done
good. A temperature might be 101° F. in the afternoon, and
next day it might be normal, the fall being due to natural
causes, the blood alone having overcome the poison.
74 SUCCESSFUL TREATMENT OF PUERPERAL FEVER.
Dr Haig Ferguson quite agreed with Dr Lackie as to the
failure of the serum to do any good even in cases where blood-
cultures and the secretion in the uterus had been examined
and the streptococcus found. In these cases one would have
expected, a priori, some advantage to have arisen from the
exhibition of the serum. Personally, however, he had seen
either no benefit, or very little, from its use. As to scraping the
uterus, it was a dangerous thing to do — opening up fresh sur-
faces. As to the use of 1 in 1000 corrosive in an intra-uterine
douche, he thought it to be very dangerous to use in a puerperal
uterus. Nothing stronger than 1 in 4000 should be employed.
Meeting III. — January 9, 1907.
Dr J. W. Ballantyne, President, in the Chair.
I. The following gentleman was elected an Ordinary Fellow
of the Society:— A. M. Crennan, M.B., Ch.B., 36 Woodburn
Terrace, Edinburgh.
Dr Haidtain showed — (a) TWISTED PAROVARIAN CYST with
an intraligamentary haemorrhage — the ovary not being at all
involved, (b) A specimen of diffuse uterine fibrosis, in
which, as usual, the mucous membrane was much hypertrophied.
(c) A sarcomatous uterus, round celled, which filled up the
entire cavity, perforated the wall, and involved the peritoneal
cavity. The operation had been performed seven or eight
months ago, and at present the patient was quite well, (d) Uterus
removed for perforating abscess of its wall. The case was one
of septicaemia after abortion. On opening the abdomen it was
found filled with purulent material, and the uterus was found
perforated. It seemed a desperate case ; the temperature was
about 104° F. at the time of operation, but the patient is absolutely
CASE OF ACUTE ALBUMINURIA, BY DR FREDERICK PORTER. 75
so far recovered, (e) Three specimens of mucous polypus and
adenomatous growth, associated with fibroid uterus. In one
of the specimens the mucous polypus is growing on the base of
a fibroid. (/) A multiple fibroid of uterus, giving rise to
retention of urine. The special interest of the specimen was,
that on the right side the tube seemed as if it had passed down
into a sulcus, which seemed to be formed by a fibroid in the
round ligament, which had turned over. But the condition was
a very difficult one to understand.
III. CASE OF ACUTE ALBUMINURIA, CAUSED BY THE
PRESSURE OF A TUMOUR ON BOTH URETERS-
OPERATION— RECOVERY.
By Dr Frederick Porter.
The President and Fellows, — I thought this case of suf-
ficient interest to place before this Society. So far, I have
failed to find any record of a case presenting a similar train of
symptoms, but there is possibly some Fellow present who has
had experience of a similar case.
Mrs M'L., age 34, multipara, has had three children, youngest
four years of age. All her labours were natural and easy. I
saw this patient first on 19th April 1905, when she complained of
general weakness, pain in the back, pain in the right hypochon-
driac and lumbar regions, especially when she walked. These
symptoms were relieved by lying down, except the pain in the
back, which was more severe. She informed me that she suf-
fered from the above symptoms for the past five years, and con-
sulted me as she was feeling more run down than usual. For
the last six or eight months her menstruation was regular every
twenty-one days, but very scanty, the period lasting one day.
There was slight dysmenorrhea. She suffered considerably
76 CASE OF ACUTE ALBUMINURIA,
from flatulence, and had every appearance of a chronic dyspeptic.
Heart and lungs were apparently sound. There were no hsemic
bruits ; pulse 74 per minute ; soft tension.
Abdominal Examination revealed on palpation a freely
movable tumour, which was easily palpable on deep inspiration,
and with slight pressure disappeared from the hand and seemed
to dip down under the liver. In size and shape it seemed to me
to have the characteristics of a large kidney, and I diagnosed
the case as a movable hydronephritic kidney. Eectovaginal
examination revealed no abnormality. Urine was acid, slight
mucus-like deposit, no albumen, sugar, or blood. Deposit on
microscopical examination revealed a number of large squamous
and pyriform cells, and a few leucocytes. I ordered the patient
a kidney belt, which relieved the back weakness, but with no
other appreciable results.
I examined the urine at intervals of a month, and found it
always practically similar to my first examination. One
specimen exhibited a larger number of squamous and pyriform
cells and leucocytes than any previous specimen.
I may here state that I examined this patient's urine so
frequently, as I was anxious to discover the significance of the
presence of these cells, as I had previously observed that in
several urines, and as I thought I was dealing with a pure
kidney condition, I might find out their exact nature. I will
refer to this later.
History of Present Illness. — On 3rd November 1905, patient
complained of severe headache.
4th November. — Headache had disappeared, and she felt in
her usual health.
5th November. — She complained of breathlessness, with a
choking sensation, and felt sick. She lay down in bed for an
hour, but as this increased the above symptoms, she rose and
sat up till her usual bed-time. She slept all night.
6th November. — Complained of breathlessness, but rose and
BY DR FREDERICK PORTER. 77
did her house duties. She noticed, when dressing, there was
considerable swelling of the lower limbs.
7th November. — Her husband noticed there was swelling of
the face and abdomen. On examining the legs at night he saw
they were swollen as far as the ankle. She complained of sick-
ness throughout the day.
8th November. — On dressing in the morning, she found she
could not get her corsets to meet, on account of the general
swelling. Her arms and hands were greatly swollen. Other
symptoms similar to the previous day, except that she vomited
twice. I was asked to see her in the evening, and found a
general oedema of the whole body. Face, arms, hands, chest,
legs, and feet, all pitted freely on pressure. She was very
breathless, and complained of pain in the right iliac region, and
said she had passed a small teacupful of urine in the twenty-four
hours. Pain in the back was still present, but she was quite
free from pain in the right hypochondriac region (the previous
seat of pain). She had very severe headache. Pulse was
regular (72 per minute), tension high.
Heart on Palpation. — Apex beat was strong and heaving,
and was shifted about \ inch to the left.
Auscultation. — Sounds were clear, second accentuated and
metallic ; there were no murmurs.
Abdomen was distended and (edematous. I could not
detect the movable tumour in the right hypochondriac region ;
over the right iliac there was resistance on palpation, and on
deep palpation she complained of pain. Percussion note in
this region was duller than the opposite side, and remained so
after patient was put in the lateral position.
Urine was alkaline, sp. gr. 1022. After adding acetic acid
and boiling, it gave a copious deposit of albumen which was
almost solid. There was also a little blood present.
Microscopically. — Eed and white blood-cells, a large amount
of epithelial cells, and a few hyaline casts.
78 CASE OF ACUTE ALBUMINURIA,
As I assumed my previous diagnosis was correct, I came
to the conclusion that the kidney was displaced into the pouch
of Douglas, and the ureter had become twisted in the process,
thus causing the nephritic symptoms.
Patient was given a saline aperient and a mixture of potass
acetate, hyoscyamus, buchu, etc., and put on a milk diet.
9th November. — Headache had disappeared ; patient passed
a normal amount of urine, which contained less albumen ; there
was no blood, but casts still present. Dr Haultain examined
the patient in the evening, and practically corroborated the
diagnosis. On vaginal examination he found a body lying in
the pouch of Douglas, which he thought might be the edge of a
kidney.
10th November. — Patient felt better ; headache still absent,
and she was less cedematous ; face was still puffy, but there was
no oedema of legs and arms. In the evening she was removed
to the Deaconess Hospital, with a view to operation.
She remained in bed till 15th November, where she felt
quite comfortable. Urine still contained a considerable amount
of albumen, and casts were still present. Mr Alexis Thomson
operated, and removed a multilocular pedunculated cyst, which
was attached to the broad ligament, and which he found pressing
on both ureters.
Patient remained in hospital a fortnight, and though the
operation was entirely successful, the nephritic symptoms did
not improve, but steadily got worse. I believe, while in hospital
the amount of albumen was estimated for the first day or two
after the operation, but when the albumen was found to be
increasing, an estimate was no longer taken. I regret that I
have no accurate notes of the daily output of albumen.
When patient returned home, 1 put her on a milk diet, gave
diuretic mixture she had previously, and kept her in bed.
The albumen steadily decreased in amount, and on 22nd January
(nine weeks after operation) there was no trace. On question-
BY DR FREDERICK PORTER. 79
ing her about the diet she got in hospital, she informed me
that two days after the operation she had been on an ordinary
convalescent diet — chicken, rabbit, milk pudding, apple tart,
etc., and this no doubt accounted for the increased albuminuria.
Her after-history was without interest, except that I found
a difficulty in getting her to take nitrogenous food without
causing a return of the albuminuria. After the urine was free
from albumen, I waited a week and supplemented the milk
diet with different preparations of plasmon, biscuits and powder,
which I ordered in milk puddings, and plasmon cocoa (this was
experimental). I found on this diet there was a return of
albuminuria. I changed the diet, and gave her oatmeal porridge,
green vegetables, tomatoes, milk puddings, and milk ad lib.
After a fortnight there was no return of albuminuria, and I
gradually introduced chicken soup, veal, tea, etc.
I examined her urine, at first fortnightly and then monthly,
but found no trace of albuminuria. She is now on an ordinary
light mixed diet, and she is in every way better. She suffers no
pain anywhere, and at present is four months pregnant. Her
urine is free from albumen, but there is still a number of
squamous and pyriform cells present.
This case, I think, may strike you as presenting some analogy
to the albuminuria of pregnancy. When I was asked to see
this patient on 8th November 1905, I had examined her urine
ten days previously, and then found no trace of albumen.
Thus there is no doubt the albuminuria was of sudden onset.
It is significant also that the movable tumour which was
situated in the right hypochondrium was no longer in that
position, and finding a dull resistant area in the right iliac
region (which previously did not exist), I feel I was justified
in the inference that the tumour was displaced into the pelvis,
and was at least a factor in causing the nephritis.
As the operation showed, my diagnosis was incorrect. Had
it been a displaced kidney with a twisted ureter, then I think
80 CASE OF ACUTE ALBUMINURIA,
the symptoms this patient suffered from might all have been
attributed to this, with some possible weakness in the other
kidney. As the case now stands — " a tumour attached to the
broad ligament and pressing on both ureters" (these are the
surgeon's words for what he found) — I feel that I cannot
logically conclude that this could be sufficient to cause such
severe symptoms in any person with healthy kidneys. The
question, I feel, that naturally follows, is : Are this patient's
kidneys healthy, or are they in a state of nephritis ? From text-
book descriptions of symptoms of nephritis, I think I am justified
in saying that this patient suffered prior to the displacement of
the tumour, and does not at the present time suffer from nephritis.
From observations I have made on urines of pregnant and other
women, and with my present knowledge of those urines, I
believe that this patient suffered from some catarrhal condition
of one or both kidneys, and I arrive at this decision from the
condition of her urine.
I fear, Mr President, I can only give you a hypothetical
reason for this belief. I have found in three cases I have met
within the last eight months a similar condition of the urine to
this patient. In two of those cases an albuminuria supervened,
one at the sixth month and another at the eighth month of
pregnancy. The other case escaped, and, I believe, on account of
a very strict diet. All I can say about the urines of those
cases is, that they all showed, microscopically, a number of large
squamous and pyriform cells and leucocytes. These may be
cells from the bladder, as authorities on the subject say that
cells from the bladder and kidney are very difficult to dis-
tinguish. My experience (which may be fallacious) has
taught me that in bladder cases it is seldom those cells are met
with so freely without the presence of pus, and whenever I find
those cells persisting in a urine, I always examine the urine
frequently, and place the patient on a strict diet, as I believe
they are suggestive of a catarrhal condition of the kidneys.
BY DR FREDERICK POUTER. 81
In conclusion, I think I might safely say that if this
patient had not sought medical advice when she did, and I had
not found what I supposed to be a movable kidney, this case
might have been diagnosed as a case of uncomplicated nephritis.
The lesson this case has taught me is to make an abdominal
and pelvic examination in acute albuminuria in women.
The President said that the Society had had an interesting
case record put before it — one that presented just the amount
of problematicalness that would lead to different opinions as to
the possible causation. Most of the Fellows were familiar with
tumours beginning in the pelvis and growing into the abdomen,
and thus giving rise to a new group of clinical features, e.g., in
fibrosis of the uterus. According to Dr Porter's explanation,
the opposite was the case in this patient, although of course the
cyst must have been down in the pelvis at the first, and had
then grown up, and been displaced downwards again. The
President cited a case where a tumour, thought to be a kidney,
had been displaced downwards, and apparently had been the
cause of a bad attack of haemorrhoids. Two years subsequently
it had been found to be a gall-bladder full of gall-stones which
was down in the pelvis.
Dr Haultain said that from the history of the case, from
the fact that the tumour had been felt in the right iliac region,
and also from the fact of the albuminuria (which he had not
seen before associated with tumours of ovary or uterus), he was
led to believe that he had to deal with a kidney, and in
accordance with his belief that gynaecologists should only take
cases associated with pelvic organs, he had asked his colleague,
Mr Alexis Thomson, to see the case and give his opinion upon
it. Mr Thomson had been vague about the diagnosis, but had
opened the abdomen, while he (Dr Haultain) had had the
pleasure of assisting him, and had found an ovarian cyst. He
F
82 CASE OF ACUTE ALBUMINURIA, BY DR FREDERICK PORTER.
thought it showed one the great importance of going very
thoroughly into these cases, but that however thoroughly one
did go into them, that sometimes one's diagnosis must be
absolutely wrong. He had operated upon a considerable
number of ovarian and fibroid tumours, and had never seen
anything like the amount of albuminuria present in this case.
What exactly had been the cause of it was difficult to say.
There had been no great dilatation of the ureters, but it seemed
as if there must have been some pressure on the ureter on one
side, although it was not noticed at the time of operation.
Abdominal section had been indicated, and the operation was
successful.
Professor Kynoch said he had had pleasure in listening to
the paper. He had been going to ask if there had been any
dilatation of the ureter, or any kinking of it, but Dr Haultain
had already said there was not any.
Dr Ritchie said that Dr Porter had, before the operation,
diagnosed a movable kidney. What was the condition of that
kidney after the operation? One of the practical lessons of
this case was that when albuminuria was present, it was of
great importance that the patient be dieted very carefully till
the albuminuria had completely disappeared.
Dr Porter, in reply, thanked the Fellows for their kind
reception of the communication. As to Dr Kitchie's question,
the patient had a general slight enteroptosis, both kidneys
were slightly movable, and the liver slightly displaced. As to
the suggestion that the albuminuria was something apart from
the tumour: it might have been so, but he had examined
frequently before, and knew the position of the tumour, then,
called in suddenly and finding no tumour, but a dullness in the
right iliac region, he was justified in taking up the explanation
he had given.
HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS. 83
IV. INTRACTABLE UTERINE HEMORRHAGE AND
ARTERIO-SCLEROSIS OF THE UTERINE VESSELS.
By Elizabeth H. B. Macdonald, M.A., M.D., Ch.B., Carnegie Research
Scholar, University College, Dundee.
Many cases of severe uterine haemorrhage, occurring near the
menopause and without obvious cause, have been reported within
recent years. The pathological findings in. these cases have
been almost as various as the constructions put on the patho-
logical conditions in the attempt to explain the haemorrhage.
Nearly all have shown thickened blood-vessels, and the
vessel changes have been regarded by many observers as the
causal factor. In particular, Eeinecke, in 1896, reported four
cases where hysterectomy was performed for bleeding, and
where the pathological examination showed the most marked
changes to be in the vessels. He explained the hsemorrhage as
due to the inability of the thickened, rigid vessels to respond
to vasomotor stimulation. Cholmogoroff, Pichevin, and Petit,
and more recently Barbour and others, have reported similar
cases. But the connection between uterine arterio-sclerosis on
the one hand, and uncontrollable uterine hsemorrhage on the
other, has not been clearly established. Cases are known
where a marked sclerotic condition of the vessels has been
unattended by haemorrhage, and the occurrence of serious
haemorrhage has been noted where the vessels showed no
marked change.
Pozzi, in 1899, still seeking the cause of haemorrhage in the
condition of the vessels, differed from other observers in finding
the thickening in and around the vessel walls due mainly to an
increase in elastic, and only to a less extent in fibrous, tissue.
The great increase in the elastic tissue of the organ gave to it,
he considered, a peculiar resistance, and paralysed its contracting
power, so that haemorrhage readily occurred. Anspach, on the
84 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
other hand, in a recent paper (1906) demonstrates the physio-
logical increase in elastic tissue in muciparous uteri, and
suggests that the cases of bleeding, which, as being in his
opinion dependent on a pathological condition of the muscula-
ture, he designates "metrorrhagia myopathica/' may be due to
a failure in the normal increase of elastic tissue.
Theilhaber, noting the extreme difficulty of distinguishing
physiological from pathological changes in the blood-vessels of
an organ subject to such functional variations as the uterus,
and believing that the majority, if not all, of the changes
described as arterio-sclerosis are conditions normal in a parous
uterus, lays stress on the part played by the musculature in
the occurrence of haemorrhage. But exactly the same difficulty
in distinguishing what is pathological from what is physiological
arises here. What is the normal proportional increase of
fibrous tissue to muscular tissue with advancing age and
repeated pregnancies? When does Theilhaber's "muscular
insufficiency " arise ?
Other observers have sought the cause of the haemorrhages
in ovarian changes. That all the causes have a very definite
connection with the periodic ovarian stimulation on which
menstruation depends, is quite clear from the histories. None
of the patients manifesting uncontrollable haemorrhages of
obscure origin was past the menopause ; and, as Barbour justly
remarks, "Arterio-sclerosis after the menopause has been
frequently described, but never as accompanied by serious
haemorrhage."
A consideration of the mode of occurrence and control, so
far as we know it, of the normal menstrual haemorrhage, may
throw some light on the causation of abnormal uterine haemor-
rhages. It is clear that the normal haemorrhage is brought
about and controlled by several factors, and that a disturbance
in any one of these may cause irregularities.
That a gradually increasing pelvic congestion occurs and
BY DR ELIZABETH H. B. MACDONALD. 85
culminates in haemorrhage mostly by diapedesis, but partly also
at the height of the congestion by rupture of some of the
endometrial capillaries, has been sufficiently demonstrated ; as
also the fact that this periodic congestion is dependent on the
ovaries. Whether the general rise of blood pressure is due to
an internal ovarian secretion exerting its influence through the
blood, or is determined by nervous influences, or depends on
both these factors, is still doubtful. But at least it is safe to
assume that variations in the normal stimulation may result in
abnormalities of menstruation.
No less important than the ovarian stimulus is the response
of the uterus, and here it will be convenient to consider
separately the response of the musculature, including the blood-
vessels, and of the endometrium.
The part played by uterine contractions in controlling
haemorrhage has been fully described by Theilhaber. He points
out that during the greater portion of the menstrual period the
uterus is large and flabby; then contractions occur which
become gradually longer, while the bleeding becomes correspond-
ingly less, until finally the flow ceases completely, strong and
continued contraction being necessary for this complete cessation.
Similarly, in the puerperium, the cessation of lochial discharge
is dependent on contraction of the muscle. Thus, he argues, if
the muscular contraction is insufficient, hyperaemia results,
with its probable secondary results in swelling and oedema of
the uterine parenchyma, and following these, long-continued
monorrhagia may readily occur. Anspach explains the actual
occurrence of menstrual haemorrhage as due to obstruction to
the venous return, whereby congestion is produced, resulting
naturally in diapedesis, the obstruction being caused by weak
uterine contractions narrowing the veins, but failing to narrow
in a corresponding degree the thicker-walled arteries. This is
essentially the view of Theilhaber, leaving us to infer that the
cessation of the haemorrhage will be brought about by con-
86 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
tractions strong enough to close the arteries as well as the
veins.
Any explanation of uterine haemorrhage that even only
apparently separates, in regard to its action, the uterine muscle
from the blood-vessels, appears to me to be defective. The
uterus may be ideally considered as a muscular expansion of
the vascular walls, as Keiffer, from his study of the histology
of the nervous system in the uterus, points out. Vasomotor
stimulation causes contraction or relaxation of the whole
uterus. The involuntary muscle of the vessel walls is to be
regarded as essentially part of the uterine musculature, subject
for the most part to the same variations and the same patho-
logical changes. From this point of view it appears possible
that during the height of menstrual congestion the pressure
within the vessels is such as to paralyse their contracting
power, and that as the pressure lessens, partly from escape of
the blood and partly probably from natural diminution of the
ovarian stimulus, the vessels regain their tone, and the uterus
responds to the vasomotor stimulation by contractions sufficient
to stop the haemorrhage. For the complete cessation of the
flow, strong and lasting contraction is necessary, but this is
brought about as a response on the part of the entire muscula-
ture to vasomotor stimulation. It follows that any cause
interfering with the normal response of the musculature may
cause irregularities of menstruation.
The response of the endometrium to the menstrual stimulus
is important and interesting. The gradually increasing con-
gestion causes a definite swelling of the mucosa, so that the
stroma cells become more distinct in outline and later polyhedral
from mutual pressure, while the glands appear larger from
swelling of their epithelial cells. The surface capillaries show
a remarkable power of distension to accommodate the increased
supply of blood, and appear also to increase in number, so that
some observers have thought that new capillaries are formed.
BY DR ELIZABETH H. B. MACDONALD. 87
But it is possible that the delicate-walled collapsible tubes
become apparent only when in a more or less distended con-
dition. The actual haemorrhage occurs by diapedesis through
these delicate capillary walls, and partly also, in all probability,
by rupture of some of them, the corpuscles finally forcing their
way between the individual cells of the surface epithelium, or,
by dislodging one or two adjacent epithelial cells, finding a
freer exit.
What is true of normal haemorrhage is true also as regards
the mode of occurrence of abnormal uterine haemorrhage.
There is no suggestion in any of the recorded cases of severe
bleeding that rupture of the presumably diseased vessels had.
occurred. The haemorrhage occurs by capillary oozing, an over-
distension of the endometrial capillaries being first produced ;
and the ease with which haemorrhage occurs depends to a
considerable extent on the healthy condition of the capillaries
and their resisting power. One would expect, therefore, that
any disturbances in the circulation, whether arising from
increased arterial supply causing over-filling of the capillaries,
or from venous obstruction producing over-distension by back-
ward pressure, would tend to produce uterine haemorrhage.
And there is little doubt that such circulatory disturbances
would result in the appearance of haemorrhage much more
commonly than they do, were it not for the peculiar character
of the endometrium, its unique readiness of response to stimu-
lation.
So far, therefore, the causes of abnormal uterine haemorrhage
fall naturally into three groups : —
1. Abnormalities in the periodic ovarian stimulation.
2. Conditions giving rise to muscular insufficiency, either
from
(a) actual deficiency of muscular tissue, or
(b) loss of tone, and consequent deficient response to
vasomotor stimulation .
88 HAEMORRHAGE AND ARTERIO-SCLEROSIS OF UTERINE VESSELS,
3. Conditions giving rise primarily to continued congestion
of the endometrium, either from
(a) increased arterial supply, or
(b) venous obstruction.
1. Of ovarian changes and their effect on menstruation, we
know comparatively little. We know from actual experiment
that the growth of the uterus depends directly on the healthy
functional activity of the ovaries, that the complete removal of
the latter results in atrophy of the uterus and of the genital
organs generally, and that the retention of even a small piece
of healthy ovarian tissue is sufficient to prevent these regressive
changes. Physiologically, there is a gradual lessening of ovarian
activity as the menopause is approached, and this is accom-
panied by these general regressive changes, atrophy of the
uterine muscle and mucosa, thickening of the walls of the
vessels with narrowing of their lumina, and the gradual cessa-
tion of menstruation.
Menorrhagia in connection with ovarian disease, especially
early cystic changes in the ovary, is well known to occur, and
was noted many years ago by Lawson Tait. The haemorrhage
in these cases is unaffected by curetting, or, indeed, by any
treatment save removal of the diseased organ. The endome-
trium often shows no appreciable change from the normal — a
noteworthy point, in view of the manifold forms of change which
it is liable to show in cases of venous congestion. Exactly how
the monorrhagia is brought about is not clear. Brennecke's
explanation of the cases which he named " endometritis hyper-
plasia ovarialis " was based on Pfluger's theory that menstrua-
tion is directly dependent on ovulation. But this theory has
since been shown to be insufficient, and Brennecke's explanation
covered only those cases where lasting congestion and consequent
hyperplasia, with monorrhagia as a secondary result, occurred.
Czempin recognised cases of severe monorrhagia unconnected
with endometrial changes occurring in association with adnexal
BY DR ELIZABETH H. B. MACDONALD.
89
diseases. These, he suggested, might be due to an exaggeration
of the normal stimulation, resulting in arterial congestion and
consequent severe and lasting haemorrhage. Since the men-
strual stimulus is associated essentially with an increased
blood pressure, producing its effects in the uterus by creating a
sudden hyperemia, it seems reasonable to suppose that an
exaggerated stimulus should result in menorrhagia.
The probability of disturbed ovarian function occurring at
the menopause is readily appreciated, and the marked con-
nection between the approaching menopause and uncontrollable
uterine haemorrhage strongly suggests the possibility of ovarian
changes being a causal factor in the haemorrhages. Cases of
spontaneous cure occurring when ovarian activity ceases and
the menopause is fully established, strengthen this possibility.
Gardner and Gooclall, in a recently published paper, refer to
such cases, and point out that if ovarian stimulation acting on
a uterus affected by "chronic metritis" is the cause of the
menorrhagia, then the menorrhagia should continue until
ovarian function ceases, the condition of the uterus remaining
unaltered. But they report a case where severe menorrhagia,
occurring near the menopause and associated with all the usual
signs of "chronic metritis," disappeared under conservative
treatment, yet normal menstruation, indicating ovarian activity,
remained.
It is interesting to note that several of the reported cases
of uncontrollable haemorrhage laid to the charge of arterio-
sclerosis or muscular deficiency have shown ovarian changes.
Thus, in the case reported by Barbour, the right ovary was
cystic, with very little ovarian substance left, while the left was
small and sclerosed ; and of Anspach's three cases of " metror-
rhagia myopathica," two showed ovarian changes to a slight
extent.
Further, it is evident that impairment of the functional
activity of the ovaries may occur independently of any demon-
90 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
strable lesion, and may be the cause of haemorrhage in those
cases where no pathological condition is found. Indeed, Freund
goes so far as to say that only in cases of bleeding from car-
cinoma has an anatomical basis for the haemorrhage been
demonstrated.
2. It is obvious, from a consideration of the part played by
the musculature in the control of menstrual haemorrhage, that
failure of the muscle to contract efficiently may be associated
with haemorrhage of the severest kind. Such failure may be
due to
(a) actual deficiency of muscular tissue. Thus, insufficient
muscular development, such as not infrequently obtains at the
time of puberty ; or actual atrophy and degeneration, such as
occurs normally at the menopause but may occur as a premature
and so far pathological change; or "sclerosis" of the uterus,
whether due to a primary diathetic condition (Brionde, Eichelot)
or a secondary result of infection (Bland-Sutton), all come
under this heading, and in all the muscular coat of the vessels
participates in the pathological changes. Without actual
deficiency of muscle, insufficient contraction may be due to
(b) loss of tone in the musculature. This may occur as a
simple atony associated with a lowering of tone throughout the
body from some general cause, and possibly then accompanied
by manifestations of muscular atony in other parts of the body,
gastric symptoms, etc., or as a local change from the various
causes, producing atony of the uterine muscle either directly or
through fatigue of the nerve- cells. The effects of various
poisons, of alcoholism, etc., on the nerve-cells has not yet been
shown, but these have possibly a direct effect in producing
atony of the musculaturei
In cases of menorrhagia arising from this cause, intermen-
strual leucorrhoea is a not infrequent symptom, the explanation
being the lowering of tone in the vessel walls and the consequent
ready escape of leucocytes. It is doubtful whether muscular
BY DK ELIZABETH II. B. MAC DONALD. 91
insufficiency alone, apart from this element of lowering of tone,
ever gives rise to leucorrhoea, since the capillaries in a healthy-
condition have a remarkable power of resisting pressure, and
accommodating themselves by enormous dilatation to an in-
creased mass of blood. Typically, deficiency of the musculature,
without deficient vitality of the vessel walls from loss of tone,
will result in menorrhagia, the hemorrhage becoming more
prolonged and profuse as the secondary hyperplasia of the
uterine parenchyma becomes more evident.
It is in this class that Theilhaber would place the great
majority of the cases of uncontrollable haemorrhage occurring
at the menopause, and in this he is enthusiastically supported
by Palmer Findley. Normally, the regressive changes in the
musculature associated with the menopause are accompanied by
corresponding regressive changes in the blood-vessels which
become accommodated to a decreased blood supply. Anything,
therefore, preventing this normal diminution in blood supply,
anything keeping the blood supply at its former level in face of
the retrograde changes in the muscle, will cause haemorrhage —
haemorrhage which these authors regard therefore as due to
muscular insufficiency. But the regressive changes in the
musculature are admittedly physiological, normal at the meno-
pause, and would not give rise to haemorrhage were it not that
the vessels are prevented from closing proportionately. It
would seem more logical, then, to regard the haemorrhage as a
result, not of the atrophied condition of the muscle, which is
physiological, but of the patent condition of the vessels, which
is pathological. It is evident that a normal blood supply acting
on an insufficient musculature will have the same practical
result as an increased blood supply on normal musculature.
The question is whether the muscular atrophy is premature
and therefore pathological, and justly to be blamed as the
causal factor in the haemorrhage, or whether the blood supply is
being maintained at a pathologically high level, either through
92 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
failure to diminish when it naturally should, or from a real, and
as yet unexplained, increase in pressure.
Although many of the reported cases of intractable haemorr-
hage show intermuscular fibrosis, with atrophy and degeneration
of muscle, yet there is no general agreement that atrophy of
muscle, beyond that occurring normally at the menopause, is
characteristic. The point is extremely difficult to determine.
Thus, in four cases reported recently by Wittek, three show
intermuscular fibrosis, and the fourth does not. But the excep-
tional case was a nullipara. Shaw, investigating cases of chronic
metritis, finds no marked increase of connective tissue at the
expense of muscular, but rather a hypertrophy of both elements,
due, he considers, to efforts on the part of the uterus to rid itself
of the thickened mucosa.
Cases of haemorrhage where the musculature is insufficiently
developed, or where its atrophy is definitely premature, are
undoubtedly to be placed in the category of myopathic haemor-
rhages. In this class also may justly be placed those cases which
have as their starting-point an acute febrile disease such as
typhoid ; or are associated with anaemic conditions, particularly
chlorosis, or with chronic wasting diseases, such as phthisis.
All these are definitely associated with changes in involuntary
muscle, and show their effects, as a rule, on the heart. Other-
wise, changes in the uterine musculature are probably for the
most part secondary to circulatory disturbances.
3. Cases of intractable uterine haemorrhage due primarily to
circulatory disturbances form an important group. Continued
congestion of the endometrium may be due to
(a) an increased arterial supply. In determining this, the
endometrium may be primarily at fault, as in cases of direct
infection, placental retention where the remnants act the part
of an irritant foreign body, and malignant disease of the mucosa.
Inflammation and tumours of the adnexa, as also tumour
formation, particularly fibro-myoma, in the uterus itself, will
BY PR ELIZABETH H. B. MACDONALD.
93
likewise determine an increased arterial supply, and to these
may be added any local irritation, mechanical or psychical.
Histologically, as Frennd has shown, this arterial congestion
will be characterised by an increase in the number of capillaries,
and a widening of the vessels, in which naturally the veins take
part more readily and to a greater extent than the arteries, the
widening in the veins being of a diffuse character affecting
mostly the capillary venous network on which the strain of the
increased blood supply first tells.
(b) Venous obstruction may arise from a general condition,
such as heart- or kidney-disease, chronic lung affections, chronic
constipation, etc. ; or from local obstructions to the venous
return, such as would be caused by tumours within or without
the uterus ; or from displacements of the uterus. The resulting
passive congestion does not, according to Freuncl, cause any
increase in the number of capillaries, but results first in
irregular dilatation of the larger veins, particularly of those in
the fundus ; the pressure may further tell back on the arteries,
and produce thickening of their walls.
Long-continued congestion from whatever cause arising,
brings about a very typical reaction in the mucosa. There
appears to be little doubt that a large number of the cases
variously described as " hyperplastic endometritis," " hyper-
trophic glandular endometritis," " interstitial endometritis," etc.,
are simply, as Van Meerdervoort describes them, secondary
results of long-continued congestion of the mucosa. The
differences in the various forms, including "fungous" and
" polypoid endometritis," are merely of degree, and he suggests
" chronic oedema " as a more correct and appropriate title for
the whole class. Lofquist arrives at very similar conclusions,
suggesting that all the various changes are degrees of what he
terms " decidual reaction." The changes are slow and gradual ;
the distension of the capillaries does not result in haemorrhage,
as in the more rapid menstrual increase in blood pressure,
94 HEMORRHAGE AND ARTERIO-SCLEROSIS OF UTERINE VESSELS,
because the tissues have time to adapt themselves to the
increased blood supply. Hyperplasia of the tissues results,
affecting first the mucous membrane, and extending in the
course of time to the entire uterus, giving one of the forms of
" chronic metritis."
Many attempts have been made to elucidate "chronic
metritis," some observers regarding it as due always to infection
of a more or less remote date, others as secondary to chronic
endometritis, others as a primary condition giving rise to
chronic endometritis by interference with muscular contraction
and consequent hyperemia. That there are many forms of
pathological change involved and so far confounded is probable.
But one form of the affection — where the uterus is generally
enlarged, with thickened walls showing no evident dispropor-
tional increase in fibrous tissue, but rather a general swelling
and hyperplasia of all the constituent elements, the endome-
trium at the same time exhibiting one or other of the usual
forms of "glandular endometritis" — is almost certainly due
primarily to a disturbance in the circulation. This is the form of
chronic metritis found in the various displacements of the uterus.
Clinically, these cases are characterised by a gradually
increasing monorrhagia, and this is what we should expect from
the pathological condition. The menstrual stimulus, normally
resulting in a comparatively rapid over-distension of the
capillaries, produces its effect more slowly through the thickened
mucosa with its already comparatively distended and more
numerous capillaries, but when haemorrhage does occur, at the
very height of the congestion, it is more profuse than normal
because of the more widely distended condition of the capillaries.
Similarly, the bleeding will last longer, partly from the lowered
tone of the vessels from prolonged dilatation, and partly from
inefficiency of the oedematous muscle, together resulting in less
efficient response to the vasomotor stimulation, and so failure
to arrest the haemorrhage with normal rapidity.
BY DR ELIZABETH H. B. MACDONALD. 95
But not all cases of venous congestion become clinically
apparent as menorrhagia. Whether abnormal haemorrhage
results, appears to depend to some extent on the resisting power
of the endometrial capillaries. The vessels of the endometrium
are peculiar. Macgregor has described them carefully, dis-
tinguishing between the "thick-walled" and the "thin-walled"
vessels. The latter are merely tubes lined by a single layer of
delicate endothelium, and show enormous power of dilatation.
The " thick-walled " vessels, on the other hand, derive support
from a condensation of the stroma cells around them, and
these, Macgregor states, while showing many changes in the
way of thickening of their walls, hyaline degeneration, etc.,
never dilate. This is open to question. The thick-walled
vessels, which it seems hardly correct to call " arterioles," may
become dilated in cases of long-continued venous congestion.
This was well shown in a recently observed case of retroflexion,
in which there had been no abnormal haemorrhage. The
mucous membrane was very markedly thickened, giving rise on
curetting to the suspicion of malignancy, and its appearances
were those of an advanced " chronic oedema," with great increase
in the number of glands and swollen stroma cells showing their
outlines and anastomosing processes in great perfection. Most
striking was the large number of dilated " thick-walled " vessels,
of globular outline and with a marked condensation of the
stroma around them. The condition was produced in all
probability by backward pressure from the long, over-distended,
thin- walled capillaries, the healthy nervous tone of the capillary
vessels preventing the relief of pressure by diapedesis. The
patient in this case was comparatively young, 32, and unmarried.
Where the congestion arises from an increased arterial supply,
there is a tendency to metrorrhagia, in addition to the menor-
rhagia commonly observed. Any sudden stimulation, mechanical
or otherwise, determining a sudden further increase in the blood
supply, may cause haemorrhage. We may suppose that the
96 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERTNE VESSELS,
explanation is a sudden dilatation from vasomotor paralysis of
the vessels formerly in a state of exaggerated tonus.
Influence of the Menopause. — In determining the causal factor
in any case of intractable uterine haemorrhage, therefore, many
conditions must be considered. After excluding the cases
probably arising from muscular insufficiency and eliminating all
the usual causes of long-continued congestion, there still
remains a class unexplained. Yet a careful consideration of
the possible known causes markedly reduces the number of
these obscure cases. Thus the patient whose case is reported
by Pichevin and Petit, had had typhoid at 30, followed by
menorrhagia, which was, however, cured by a supervening
pregnancy, but returned in a severe form demanding hysterec-
tomy after another pregnancy two years later. Again, of
Pozzi's cases, while the elastic tissue proliferation on which he
lays stress may mean nothing more, according to recent
researches, than that the uteri examined were parous, one case
had had typhoid, and the other had had chlorosis, and at the
time of operation had albuminuria, an important symptom of
increased blood pressure. It is of further interest to note that
none of these patients was very near the menopause.
Those cases becoming evident only at the menopause have
probably their origin in circulatory troubles, the congestion
having lasted perhaps for years previously without giving rise
to any troublesome symptoms.
We do not know how ovarian activity acts in maintaining
the uterus in a healthy condition, but a twofold action at least
suggests itself. The periodic vasomotor stimulation causing
reflex contraction maintains the musculature in an efficient
working condition ; and ovarian secretion in some obscure way
preserves a healthy uterine tone. When ovarian stimulation
begins to fail, the uterus suffers in this twofold way, so that
there is a certain amount of atrophy from disuse, and a tendency
to degeneration from the cutting off of some trophic influence.
BY DR ELIZABETH H. B. MACDONALD. 97
These effects will be equally produced in a uterus already
affected by hyperplasia from continued congestion, and they
are sufficient to determine the disturbance of compensation
which results in monorrhagia. The menstrual stimulation is
essential in starting the haemorrhage; the prevailing uterine
conditions prevent its normal arrest.
Pathological Changes in the Uterine Blood -vessels, and their
Influence in Determining Hemorrhage. — So far the vessels have
been dealt with as essentially part of the uterine musculature,
and in no way to be regarded as of primary importance in the
causation of haemorrhage. But arterio-sclerosis has been so
extensively regarded as the causal factor that the subject deserves
special attention.
There can be no doubt that the vessel changes designated
"arterio-sclerosis" are in many cases normal changes, and in
no way to be regarded as responsible for the occurrence of
uterine haemorrhage. Exactly similar changes are found un-
connected with haemorrhage. Marked degenerative changes,
designated by Anspach "periarterial" and "perivenous" de-
generation occur normally in every parous uterus. In a
specimen stained by haematoxylin and eosin these areas appear
pink with few and scattered nuclei ; with Van Gieson's picro-
fuchsin method they appear a brighter yellow, in clear contrast
to the yellow of surrounding muscle; and with Weigert's
resorcin-fuchsin stain for elastic fibres they take a dark blue or
black colour. This definite increase in elastic tissue round the
vessels is characteristic, and appears to occur during the puer-
perium. The elastic tissue of the uterus generally is increased
with every pregnancy, so that it is always possible to tell a
parous from a non-parous uterus in a Weigert preparation. The
fine elastic fibrils become thickened and curled, and show a
tendency to clumping. In the vessels, the inner elastic lamina no
longer appears as a clear, unbroken, wavy fibre, but is thickened
and broken up, and there is an increase of elastic fibrils through-
G
98 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
out the media. Melnikow-Easwendenkow believes that the place
of lost parenchyma in any organ is taken by elastic tissue. Pick
records a case of uterine haemorrhage resisting treatment in a
woman of 63, which may have been due to an evident failure in
the normal increase of elastic tissue around the uterine vessels.
The normal involution of arteries after pregnancy is to be
distinguished from a pathological change. Naturally there is
enormous hypertrophy of the entire musculature in the gravid
uterus, with new formation of blood-vessels, many of which
must undergo entire obliteration during the process of involu-
tion. This is brought about by a process recognised as
"endarteritis obliterans," in which there may be enormous
overgrowth of the intima, practically occluding the vessel;
contraction of the new-formed connective tissue throughout the
media and in the adventitia helps the process. Normally there
is a slight increase of fibrous tissue at the expense of muscle
when involution is completed ; the vessels share in this, their
adventitial coats being relatively slightly thickened after each
pregnancy. It appears, therefore, that thickening of the
intima, with irregular increase in its elastic tissue, thickening
of the media, with increase in the fibrous tissue of both media
and adventitia; later, degeneration of the coats and of the
surrounding tissue, with deposition of elastic tissue, may all
occur as physiological changes.
The following case, in which the uterus was removed on
account of severe menstrual pain, and which is probably
primarily one of glandular endometritis due to infection, the
changes in the musculature being secondary, shows vascular
changes which may be taken as physiological for a uterus with
a corresponding history : —
Mrs K., aged 36, was admitted to the Dundee Eoyal In-
firmary on 4th December 1905. She had been married
eighteen years, and has had nine pregnancies, the last five
BY DR ELIZABETH H. B. MACDONALD. 99
years ago. The first two pregnancies resulted in miscarriage
at the third month, the third was normal, the fourth was
premature (twins at the sixth month), the fifth ended in a
miscarriage at the fifth month, the three following were normal,
and the last ended in a miscarriage at the fifth month. Menses
began at 14, occurring regularly every three to four weeks,
unaccompanied by pain. She had some trouble which she
described as a " growth of the womb " after the seventh preg-
nancy, eight years ago, but this disappeared under treatment by
" douches and medicine." Since the last pregnancy she has not
felt well, and for more than a year has had severe menstrual
pain, which has become much worse during the last two or
three months. The pain lasts from two days to a week, beginning
before the onset of the discharge; is worst for two or three
hours after the onset, and continues after the flow ceases. The
pain makes her sick. The discharge is normal in amount and
character, and there is no intermenstrual discharge. She suffers
from severe headaches and occasional frequency of micturition.
On admission, she was found to be thin and pale, and as the
physical examination gave rise to the suspicion of interstitial
fibro-myoma of the uterus, hysterectomy was decided on.
Operation. — ProfessorKynoch removed the enlarged uterus by
the vaginal route. The patient made an uninterrupted recovery.
Path. No. 4559. — The specimen consists of the uterus, which
is generally enlarged, measuring, after hardening in alcohol, 10 J
cm. x 5 cm. x 5 cm. On section, the uterine walls are seen to
be thickened, and the endometrium to be strikingly thickened.
The uterine cavity is 8 cm. long; the anterior wall at its
thickest part measures 2J cm., and the posterior 2J cm. The
mucous membrane shows a smooth undulating surface of a
pinkish colour, and is of normal thickness in the cervix, greatly
thickened just above the internal os, and less markedly
thickened towards the fundus ; at its thickest part it measures
on the anterior wall 7 to 8 mm., and on the posterior 9 to 10 mm.
100 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
Histological Examination : Mucous Membrane. — The most
marked change is the great increase in the number of the glands,
a few of which are dilated. The glandular epithelium is
swollen and oedematous. The stroma is loose and oedematous,
and the vessels show marked condensation of the stroma
around them. The junction between mucosa and muscle wall
is strikingly irregular, glands penetrating the muscle to an
unusual depth, and carrying with them strands of stroma
(Kg. 1).
Musculature. — The proportions of muscular and fibrous
tissue appear about equal. The tissues are oedematous, the
muscle nuclei appearing swollen, and patches of embryonic cells
are seen throughout the musculature between the muscle
bundles.
Vessels. — The larger arteries are thickened in all their walls.
The lumen is irregular in many cases, from projection of the
media and occasionally of the intima. With Weigert's stain
these irregular projections of the intima are seen to contain a good
deal of elastic tissue, and the thickened inner elastic lamina is
well shown, as also the deposition of elastic tissue in and around
the degenerated adventitia. The intimal thickenings are shown
to be almost entirely fibrous by Van Gieson's stain, and the
degenerated areas around the vessels appear bright yellow.
The media appears rather poor in nuclei, and the degenerated
areas are almost free of nuclei, in a hgematoxylin preparation.
The " periarterial " degeneration is very marked is some parts,
especially in the smaller vessels near the endometrium (Fig. 1).
Some of the arteries show a remarkable proliferation of the
intima causing almost complete obliteration of the lumen. The
veins show similar changes. There is an irregular proliferation
of the inner coat, with an increase in fibrous tissue, and a
thickening of the outer coat with degeneration extending into
the surrounding tissues — "perivenous" degeneration (Figs. 6
and 7).
BY DR ELIZABETH II. B. MACDONALD.
101
The case is of interest in several ways. The enormous
hypertrophy of the endometrium in the absence of any tendency
to haemorrhage, and the marked penetration of the glands into
the underlying muscle without in the least suggesting a malig-
nant process, are evidences that the primary trouble is in the
endometrium. Cornil noted this penetration of the glandular
elements as characteristic of chronic metritis. The cause of
the pain is obscure. Possibly it was simply an exaggeration of
the pain commonly experienced at the height of menstrual
congestion: possibly the much thickened mucosa, acting as a
foreign body, induced more severe contractions than normal
in the endeavour of the uterus to expel the foreign body, and
the increased blood pressure from ovarian stimulation in the
premenstrual stage started the contractions, which became more
severe as the congestion increased. The increase in the
musculature may then be of the nature of a true " work-hyper-
trophy." The existence of patches of embryonic cells throughout
the entire muscle wall, but most commonly in its inner half, is
noticeable, and suggests extension of an infective process from
the endometrium. Probably the case is to be classified as one
of chronic metritis, secondary to chronic infective endometritis,
the musculature being as yet but slightly affected by the
infective process.
The senile changes occurring in the uterine vessels are
illustrated in the following case : —
Mrs D., aged 51, millworker, was admitted to the Dundee
Eoyal Infirmary on 7th May 1906. She had had seven
pregnancies, all normal, the last twenty-one years ago. Menses
began at 13, and occurred regularly every twenty-eight days,
lasting for two days, the discharge being scanty and accom-
panied by slight pain ; the menopause occurred four years ago.
For two years there has been a white discharge, fairly copious,
and lately the discharge had been bloody at times. She had
102 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
been in the Infirmary in the beginning of 1905, with symptoms
of mitral incompetence, some chest trouble and diarrhoea
suggesting enteritis, and again in February 1906, with gastro-
intestinal symptoms.
Physical Examination. — Patient is a worn-out old woman,
and was intoxicated on admission. She has a slight cough;
there are dullness and tubular breathing without accompani-
ments at the left apex. There is a soft systolic mitral murmur.
She complains of frequency of micturition. Examination under
chloroform showed the cervix to be much shortened, the
vaginal aspect normal except for small submucous haemorrhages.
There was bleeding from the orifice. A swelling, possibly the
fundus, was felt lying to the left; and, suspecting malignant
disease of the body of the uterus, Dr Buist decided to do
vaginal hysterectomy.
Operation. — Dr Buist operated on 18th May. An incision
was made in the posterior fornix and into the pouch of Douglas.
A tumour mass was found on the left side, nodular, and not
very mobile. The right broad ligament was crushed and
divided, and the fundus brought down, when the uterus was
seen to be small and senile, but otherwise apparently normal.
The tumour mass could not be brought down, and median
cceliotomy showed it to be in the sigmoid flexure of the colon
with the left uterine appendages adherent. The adhesions
were crushed and divided and the hysterectomy completed.
The sigmoid tumour was isolated by Kenton's clamps and
removed, and the bowel sutured end to end.
The condition of the patient after the operation was never
very hopeful, owing to the chest condition, and on the 21st an
offensive vaginal discharge set in, becoming later putrid and
black in colour, and death occurred on the 22nd.
Path. No. 4750. — The specimen consists of the uterus,
which is normal in contour but smaller than usual, measuring
6 cm. x 3J cm. x 2| cm. The cervix appears normal save for a
BY DR ELIZABETH H. B. MACDONALD. 103
few subepithelial haemorrhages. The vessels entering the
uterus are visibly thickened and prominent, and on section of
the uterus the vessels stand out very distinctly in the vascular
zone at the junction of the middle and outer thirds of the wall.
Within this zone, extending into the mucosa, the muscular wall
presents a curious, firm, homogeneous appearance. The mucosa
is atrophied, and stained with blood in some places; its limits
cannot be distinguished by the naked eye. The uterine wall
measures 1J cm. in thickness, and is firm.
Histological Examination : Mucous Membrane. — This is
atrophied to a considerable extent, the glands persisting in
groups between which fibrous tissue strands run right up almost
to the surface epithelium. In many parts fibrous strands run
along under the epithelium. The persisting glands are small,
with swollen epithelial cells. There is considerable extravasa-
tion of blood into the mucosa, while here and there red blood
corpuscles may be seen making their way to the surface between
the individual cells of the intact surface epithelium. The stroma
is dense and its component cells are swollen and cedematous ;
fibrous strands invade it in all directions.
Muscular Wall. — The muscle is everywhere separated up
by bands of fibrous tissue. The muscle shows evidence of
degeneration and atrophy, its nuclei, especially near the
endometrial surface, being swollen and degenerate-looking, and
occasionally fragmented.
Vessels. — The vessels occur in characteristic groups, with
very narrow lumina (some appear entirely obliterated) and a
wide area of degeneration surrounding them (Fig. 2). These
areas are so extensive that neighbouring areas closely approach
each other, and give a very striking appearance to the stained
section, in which the degenerated tracts are readily recognised
by the naked eye. The process is most marked in the middle
third of the muscular wall (the homogeneous area). These
areas stain darkly with Weigert's stain, although no definite
104 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
structure can be made out in them (Fig. 3), and they appear
bright yellow, in contrast to the yellow of the muscular tissue,
in Van Gieson preparations, with an occasional remnant of red,
fibrous tissue, persisting in the midst of the structureless yellow
mass (Fig. 2). The larger vessels of the vascular zone show
various degrees of thickening and degeneration of their walls.
Many show calcification commencing between the intima and
the media (Fig. 8). The intima is not particularly affected
throughout; with Weigert's stain it shows a thickening and
breaking up of the internal elastic lamina. There are irregular
projections into the lumen in many cases, but these appear to
be due mostly to an irregular proliferation of the media, over
which the uniformly thickened intima extends. Both media
and intima are degenerated, nuclei being very few and far apart.
The adventitia is thickened throughout, and the degenerated
areas in and around the adventitia stain deeply with Weigert's
elastic stain. The increase in the adventitia appears to be due
chiefly to elastic tissue, with which the media also is spun
through, the elastic fibres again blending into a definite layer at
the internal elastic lamina. The veins show similar changes.
There is an increase of fibrous tissue in the inner coat, and a
marked deposition of elastic t\ssu>e in the degenerated outer coat.
There was thrombosis of a branch of one of the ovarian arteries
where it entered the uterus at the broad ligament attachment —
a thombosis evidently of ol^ ; landing, since there was organisa-
tion with formation of new vessels in the midst of the thrombus.
The senile change in this case was very advanced consider-
ing the age of the patient, but the fact that when admitted to
hospital she was in a state of intoxication, throws some light
on the cause of the premature senility. From the histological
examination, the case appears to have some points in common
with those cases reported as " apoplexia uteri " by von Kahlden
and others, where there was hemorrhagic infiltration of the
endometrium, associated with sclerosis of the uterine arteries.
6—
Fig. 1. — Path. No. 4559. No haemorrhage. "Periarterial" degeneration in small
vessels near the mucosa. Note also the unusually deep penetration of the glands
into the muscle, and the cellular infiltration between muscle bundles. Hsema-
toxylin and eosin. (x 50.)
a, a\, Degenerate areas round small arteries,
musculature.
b, Glands penetrating
[Inset, pages 104-105,
Fig. 2.— Path. No. 4750. Senile case. Extensive "intramural" and "periarterial" degene-
ration in vessels near the mucosa, with marked narrowing of lumina. Van Gieson. The
degenerated areas stand out in sharp contrast to the surrounding tissue, which is exten-
sively fibrous, (x 65.)
a, a1, Narrow ring of fibrous tissue, remains of adventitia.
Fig. 3. — Same group of vessels as shown in previous figure. Weigert's elastic stain.
Note persistence of internal elastic lamina, and presence of elastic tissue, which
appears black, in area corresponding to light (yellow) area in previous figure, (x 65.)
a, Inner elastic lamina.
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BY DR ELIZABETH H. B. MACDONALD. 105
The occurrence of the leucorrhoea, beginning two years after
the menopause, is undoubtedly to be associated with the dis-
turbed compensation in the heart, which became evident about
the same time. Later, the venous obstruction resulting from
the sigmoid cancer added to the circulatory disturbance in the
uterus, and the discharge thereupon became haemorrhagic and
more troublesome and persistent.
It is evident, therefore, that even very advanced premature
senile change in the uterine vessels, with calcification in some
of the arteries, and consequent rigidity, degeneration of vessels
throughout the entire uterine wall, along with marked fibrosis
of both musculature and endometrium, are all insufficient of
themselves to cause serious haemorrhage, even in the presence
of an incompetent heart. It is equally evident that in a normal
senile uterus, an incompetent heart and venous obstruction
such as would arise from cancer of the sigmoid flexure would
not necessarily give rise to any uterine symptoms. The local
condition determining the discharge in this case is probably
the premature degeneration of the vessels, diapedesis through
their degenerated and " toneless " walls, in presence of a sluggish
arterial supply on the one hand, and venous obstruction on the
other, being unusually easy. Alcoholism as a factor in bring-
ing about this premature decay of the vessels is well known,
but how the effect is produced is still obscure. The absence of
the periodic menstrual stimulation in this case sufficiently
accounts for the absence of sudden severe haemorrhages.
Several cases have been reported where severe uterine
haemorrhage was associated with general arterio-sclerosis.
But this association does not simplify matters at all, except
so far as to make it probable that the uterine arterio-sclerosis
found was of a similar nature to the general change.
Many cases of general arterio-sclerosis never show uterine
haemorrhage. So in cases of bleeding where there is a history
106 HEMORRHAGE AND ARTERIO-SCLEROSIS OF UTERINE VESSELS,
of syphilis many years previously. Syphilis we know to be
one of the most common causes of general arterio-sclerosis.
But by no means all cases of syphilis are attended by uterine
haemorrhage. What determines the occurrence of the haemor-
rhage in some cases ?
The following case is of interest : —
E. M., aged 50, unmarried, was admitted to the Dundee
Royal Infirmary on 30th April 1906. One pregnancy (twins,
six months) twenty years ago, since which time she has been
blind (coloboma, chronic iritis, cataract). Menses began at 15,
and occurred every three to four weeks, lasting seven days.
Irregular bleeding began in November 1903, the first haemor-
rhage lasting seven weeks, unaccompanied by pain, the second
coming on after an interval of five weeks and lasting for four,
and the third, after an interval of six weeks, lasting for five
weeks, at which time she was curetted, the curettings showing
nothing noteworthy. The physical examination at this time
showed the os to be patulous, edges oedematous and slightly
rough ; the fundus was nearly 3 inches above the symphysis ;
there was slight tenderness in the left iliac region, and here the
left tube could be palpated as a smooth, fairly firm, elastic oval
swelling. There was uterine haemorrhage on manipulation.
The bleeding recommenced eleven days after the curettage, and
recurred at intervals up to the time of admission, the last
haemorrhage having begun two months before admission, and
continued up to that time.
Physical Examination. — Patient is very weak, giddy, and
faint. There is slight pain all over the abdomen. She is pale,
with dilated capillaries on the cheeks. Pulse 104, of "water-
hammer " variety ; and examination of the heart shows presence
of aortic systolic and diastolic murmurs.
Operation. — Hysterectomy was performed by Dr Buist a
week after admission. A perivaginal incision was made, and
BY DK ELIZABETH H. B. MACDONALD 107
a roughly " banana-shaped " hydrosalpinx of the left side
removed, clear fluid escaping. The left ovary, which was
slightly cystic, was crushed and removed; and the normal
right ovary was left. The patient died on the second evening
after the operation, and the post-mortem examination showed
widening of the aorta, with some atheroma; the kidneys con-
tracted and unequal in size, and the liver fatty.
Path. No. 4738. — The specimen consists of the uterus, and
the cystic left tube. When inflated the tube appears roughly
to be equal in size and similar in shape to a banana, with an
extremely thin, smooth, transparent wall.
The uterus is of normal contour, but generally enlarged;
the serous surface is smooth and free from adhesions. The lips
of the cervix are somewhat hypersemic and very slightly
nodular; the cervix is 3 J cm. broad, and shows a transversely
oval aperture measuring 1J x 1 cm. The uterus measures
9 \ cm. x 5 \ cm. x 4 J cm. ; the cavity from fundus to external
os measures 7J cm. ; in breadth, from the centre of the canal
outwards in the direction of the right cornu, it measures 1J cm.,
but in the direction of the left cornu, owing to the hydrosal-
pinx, is reduced to f cm. The muscle appears normal, though
very pale, and the blood-vessels appear distinctly on the cut
surface. The mucous membrane is uniformly smooth and
pale, measuring 1 to 2 mm. in thickness on the anterior wall,
which itself measures 2 J cm.
Histological Examination : Mucous Membrane. — The surface
epithelium is intact and smooth throughout the greater part
of the cavity; towards the fundus it shows a tendency to
become polypoid. The glands are not increased in number, but
appear larger than usual, with very markedly swollen epithelial
cells. The stroma is oedematous, and its cells swollen, and
many large dilated blood spaces lined by a single layer of
endothelium are to be seen just beneath the surface epithelium.
The thick-walled capillaries appear normal in many cases, but
108 HAEMORRHAGE AND ARTERIO- SCLEROSIS OF UTERINE VESSELS,
some are thickened by condensation of the stroma around
them, and one or two show hyaline degeneration (Fig. 13).
Vessels having definite fibrous and muscular walls are found
within the mucosa, occurring often quite close to the glands
(Fig. 12), and in sections stained by Weigert's stain for elastic
fibres, these show a well-marked inner elastic lamina.
The junction between mucosa and muscle is sharply
marked, and here the number of dilated lymphatic spaces and the
numerous groups of vessels with thickened walls are striking.
Muscular Wall. — The muscle appears on the whole well-
preserved. There is no marked increase in the amount of
fibrous tissue, but in some parts the fibrous tissue which
throughout the specimen penetrates between the individual
muscle fibres, appears to have increased and produced atrophy
of the enclosed muscle fibres. No broad bands of fibrous tissue
are to be seen in the specimen except such as form the adven-
titial coats of the larger vessels. The fibrous tissue throughout
shows a tendency to degenerate.
Vessels. — The larger vessels in the vascular zone show a
marked thickening of all their coats. In the arteries, the
intima, as a rule, is irregularly thickened, forming definite pro-
jections into the lumen in some cases. In sections stained by
haematoxylin and eosin, the thickened intima is seen to be poor
in nuclei and more or less degenerated ; with Van Gieson's
stain there appears a considerable increase in fibrous tissue
which is markedly degenerated; while Weigert's elastic
stain shows a definite increase in elastic fibres throughout the
intima in many of the larger arteries. This is strikingly seen
in a branch of the uterine artery at its point of entrance to the
uterine wall (Fig. 14). The media also in this vessel is greatly
thickened, and while the muscle nuclei are fairly well pre-
served, as seen in a haematoxylin preparation, there are signs
of atrophy of the muscle in parts. The muscle fibres are seen,
in a Van Gieson preparation, to be interpenetrated by i
BY DR ELIZABETH II. B. MACDONALD. 109
degenerating fibrous tissue, which apparently presses on
and destroys the muscle cells. This is also to be seen in
the arteries within the uterine wall, though to a much less
extent; the usual condition is a hypertrophy of the media
without evident degeneration. The adventitia is thickened
and degenerated in the larger arteries, appearing in Van Gieson
sections as a grandular red or pink mass, and not taking
Weigert's stain. The veins do not show much change from
the normal. In some cases both coats are thickened, the inner
showing irregular proliferation filling up the lumen, and the
outer showing an increase in elastic tissue, which also extends
in fine fibrils through the inner coat. The smaller arteries
show swelling of the endothelial cells as a rule, or slight
irregular proliferation of the intima ; slight thickening of the
media ; and marked thickening in the adventitia (Figs. 9 and
10). The groups of vessels so affected occurring amongst the
glandular tissue at the junction of mucosa and muscle are
particularly striking (Fig. 11).
Cervix. — There is a cystic condition of some of the glands,
and here and there a subepithelial hemorrhagic infiltration.
The vessels are slightly thickened in all their coats, but there is
no marked increase in the elastic tissue. The arteries retain
their well-marked internal elastic lamina, which appears
thickened only in one or two of the larger vessels.
It is noticeable that in this case there is no typical
"periarterial" or "perivenous" degeneration. The degenera-
tion here is in the fibrous tissue of the thickened adventitial
coats, the degenerated areas looking pink and granular with
Van Gieson's stain, and not staining at all with Weigert's.
So far, it might appear that there is a failure in the normal
increase in elastic tissue. But, on the other hand, there is, in
the larger vessels particularly, a definite increase in elastic
tissue in the intima; and the uterus in this case had been
only once pregnant. The possibility of infection must not be
110 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
overlooked, since there was evidence of adnexal inflammation.
Addinsell describes degeneration of the fibrous tissue as the third
stage of the pathological process in " chronic infective metritis."
Certainly failure of increase in the elastic tissue will not
explain the haemorrhage in another case examined, that of a
woman, aged 45, with a history of severe monorrhagia for ten
years, and in whom death suddenly occurred three months
after curetting, from septic peritonitis, evidently originating
from an acute endometritis (Path. No. 2505). The vessels
show marked and extensive degeneration within and around
their walls (Fig 4). The intima is not markedly affected, but
the media in most of the larger arteries is very greatly thickened
and degenerated ; and in the most advanced cases both media
and adventitia are represented in Weigert sections as solid
clumps of elastic tissue (Fig. 5). The veins have thickened
inner coats of well-formed fibrous tissue, and show an increase
in elastic tissue in their outer coats, in the position occupied
by degenerated areas of few nuclei in hematoxylin and eosin
preparations. The vessel condition is practically identical with
that found in the senile case already described, although the
changes have not extended to the smaller vessels to the same
extent. The musculature in this case is separated up by bands
of fibrous tissue, which is well formed and not degenerated.
The cause of the menorrhagia is not evident.
Is there, then, an arterio-sclerosis of the uterine vessels
apart from that brought about by physiological causes ? If so,
will the condition necessarily be accompanied by hemorrhage ?
If we consider how the physiological changes are brought
about, the question becomes clearer. Westphalen and Thoma
have endeavoured to show that the peculiar vessel changes in
the uterus are essentially due to the changes in blood pressure
to which the functionally active uterus is subject. The periodic
increase in blood pressure at the menstrual periods, and still
more the pressure changes incident to pregnancy and thfl
BY DR ELIZABETH H. B. MACDONALD. Ill
puerperium, cause changes in the uterine vessels to which no
other vessels in the body are subject to the same extent. The
uterine vessels are, so to speak, shorter-lived than any others.
If, now, it be supposed that changes in blood pressure in these
arteries arise from some pathological condition, apart from
pregnancy, etc., similar changes will presumably occur.
Theoretically, we may suppose that persistent high tension
in the uterine and ovarian arteries will bring about as a first
result, through increased vasomotor stimulation, an exaggerated
response on the part of the musculature, so that a true " work-
hypertrophy" takes place, i.e., hypertrophy of the uterine
muscle generally, including the muscular coats of the arteries.
Since arteries acquire their coats in proportion to the pressure
they are called on to resist, it is probable that the adventitia
will be strengthened by an increase in fibrous tissue. The
strain must necessarily tell on the intima. In all parous uteri
the inner elastic lamina of the arteries is thickened. In the case
described, where general arterio-sclerosis was present, the
larger arteries showed a marked increase in elastic tissue in the
intimal coats. Probably this is the nature of the compensatory
change when the artery wall is subjected to a sustained increase
in blood pressure. Later the continued pressure will bring
about degenerative changes ; in the intima, whose nuclei dis-
appear to a great extent; and in the media, where fatty
degeneration and atrophy of the muscle may occur. We may
further suppose that if the increase in pressure be gradual and
sustained, as would occur in a case associated with general
arterio-sclerosis, the compensatory change will extend gradually
to smaller and smaller branches of the vessels, reaching eventu-
ally the endometrial capillaries. When degenerative changes
have occurred, and the vessels can no longer react to the
increased blood pressure, in other words, when compensation
is disturbed, haemorrhage will result. The importance of
menstruation in starting the haemorrhage has already been seen.
112 HEMORRHAGE AND ARTERIO- SCLEROSIS OF UTERINE VESSELS,
All these changes are illustrated in the case described
above, in which there was general arterio-sclerosis, and a fairly
clear history of syphilitic infection dating back twenty years.
The peculiar pathological features in the case are — (1) the
very distinct affection of the intima, which showed irregular
proliferation and an increase in wavy elastic fibres out of all
proportion to the general elastic increase, whixm was only very
slightly marked, throughout the uterus ; (2) the marked fibrosis
around the vessels, particularly the smaller vessels, unassoci-
ated with fibrosis of the uterus generally ; (3) the occurrence
of groups of thickened vessels at the junction of mucosa and
muscle, and the tendency of these vessels to invade the mucosa ;
(4) the existence of vessels with definite walls and a well-
marked internal elastic lamina within the mucosa, and thicken-
ing and degeneration of the " thick-walled " endometrial
capillaries.
The case is clearly one of uterine arterio-sclerosis associated
with general arterio-sclerosis. A clear case of pathological
uterine arterio-sclerosis existing as a purely local condition has
yet to be demonstrated.
The changes in the vessels due to physiological processes
cannot be regarded as causes of haemorrhage. They may go to
an extreme degree without the occurrence of any abnormal
bleeding. This is only natural. Further, since these changes
are essentially brought about by the changes in blood pressure
associated with the functionally active uterus, they are possibly
indistinguishable from changes due to a pathological increase
in blood pressure. In the causation of haemorrhage, the import-
ant thing is the pathological increase in blood pressure which
gives rise to the vessel condition. To speak of the arterio-
sclerosis as the cause of the haemorrhage is a mere confounding
of words. The haemorrhage is a symptom of the condition of
which the arterio-sclerosis is a sign. The association between
hyperpiesis and arterio-sclerosis in other parts of the body is
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Fig. 8.— Path. No. 4750. Senile case. Calcareous degeneration beginning in
superficial layers of media in large artery, (x 30.)
a, Intima. b. Media, c, Calcifying area.
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Fig. 11.— Same case as Figs. 9 and 10. Group of thickened vessels occurring
just under the mucous membrane. ( x 90.)
a, Mucosa, a1, Detached glandular epithelium, b, Muscle.
Fig. 12. — Same case as above. Weigert. Small vessels with definite walls and well-marked^
internal elastic laminse occurring within the endometrium. ( x 200.)
a, a1, Unstained glandular epithelium, b, Unstained stroma of mucosa,
c, c1, Inner elastic lamina.
Fig. 13.— Same case as above " Hyaline " degeneration of an endometrial capillary.
Note the circular arrangement; of the stroma round the vessel. ( x 230.)
Fig. 14.— Same case as above. Irregular proliferation of intima in a branch of
uterine artery where it enters the uterus. . Hematoxylin and eosin.
a, Intima. b, Media, c, Adventitia.
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BY DR ELIZABETH H. B. MACDONALD. 113
well known though not clearly understood. It seems clear in
some cases that the increased blood pressure precedes the
change in the vessels and is the cause of it, although the case
is complicated by the fact that the vessel change may itself
induce a rise in blood pressure by increasing the peripheral
resistance. The real difficulty is that the aetiology of arterio-
sclerosis occurring anywhere in the body is still obscure.
After all the well-established causes, including syphilis,
alcoholism, various forms of poisoning, etc., have been excluded,
there remains a class of unexplained cases arising independently
of these causes in comparatively young people, and associated
in some way with an increased arterial tension. Similar con-
ditions may arise in the uterus, possibly associated with some
form of local toxaemia. But the essential point is the condition
behind the vessel change. It is readily conceivable that if an
increase in arterial pressure occurred suddenly, or occurred in a
uterus of deficient musculature, haemorrhage of a severe kind
might occur before any marked changes in the vessels had had
time to occur. Thus Simmonds' case of uncontrollable haemor-
rhage showed a sclerosis of the uterine artery alone. At the
opposite extreme are those cases where the changes have
extended to the vessels of the endometrium, and where the
diagnosis can be made from curettings.
Eeferences.
1. Addinsell (A. W.). — " Chronic Infective Metritis," Journ.
Obst. and Gyn. Brit. Empire, July 1906, vol. x., No. 1.
2. Anspach (B. M.). — "Metrorrhagia Myopathica," Amer.
Journ. Obst., Jan. 1906.
3. Bandler. — " The Ovary : its Eelations to Normal Functions
and to Pathological States," Med. Record, 1901, p. 405.
4. Barbour (A. H. R). — "Climacteric Haemorrhage due to
Sclerosis, etc.," Obst. Trans. Edin., vol. xxx., p. 71.
H
114 HEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
5. Bland-Sutton. — Brit. Med. Journ., 1899, vol. i., p. 840.
"Fibrosis of Uterus," Brit. Med. Journ., 1904, vol.
ii., p. 1072.
" 100 Hysterectomies, etc.," Lancet, 27th May 1905,
p. 1406.
6. Boldt (J. H.). — " Cavernous Angioma of Uterus," Amer.
Journ. Obst., Sept. 1893.
7. Berissoff (A.). — "Ueber die Veranderung der Uterus-
schleimhaut bei Fibromyomen in Zusammenhange mit
Uterusblutungen," Monats. fur Geb. und Gyn., vol. ii.,
pt. 5, p. 351.
8. Brennecke. — "Zur Etiologie der Endometritis fungosa,"
Archivfilr Gyn., 1884, vol. ii., p. 455.
9. Brionde. — "De la sclerose de l'uterus," La Gyn., 1896, vol. i.
10. Cholmogoroff. — "Sklerose der Uterusarterien," Monats.
fur Geb. und Gyn., vol. ii., p. 692.
11. Cornil. — "Lecons sur l'anat. pathol. des metrites, etc."
Paris, 1889.
12. Dickinson (R L.). — "The Intractable Menorrhagias of
Arterio-sclerosis of the Uterus," Brooklyn Med. Journ.,
Feb. 1906, vol. xx„ No. 2.
13. DolfIris (J. A). — "Troubles ut6rins d'origine degenerative,"
La Gyn., April 1901 and June 1901.
14. Dunning (L. H.). — "Acute Senile Endometritis," Journ.
Amer. Med. Associa., 3rd Nov. 1901.
15. Findley (Palmer). — "Arterio-sclerosis of Uterus," Amer.
Journ. Obstet, 1901, vol. i., p. 30.
" Arterio-sclerosis of the Uterus as a Causal Factor
in Uterine Hemorrhage," Amer. Journ. Obstet., July
1905, p. 71.
16. Freund. — " Zur Lehre v. d. Blutgefassen der normalen und
kranken Gebarmutter." Jena, 1904.
17. Gardner and Goodall. — "Chronic Metritis and Arterio-
sclerotic Uteri," Brit. Med. Journ., 3rd Nov. 1906.
BY DR ELIZABETH H. B. MACDONALD. 115
18. Gottschalk. — "Eine besondere Art. seniler, hamorrhagi-
scher, leukocy tarer Hyperplasie der Gebarmutterschleim-
haut," Archivfilr Gyn,, vol. lxvi., 1902, p. 169.
19. Grube. — "Ueber unstillbare Uterusblutungen und Art.
Sklerose, etc.," Centralbl fur Gyn., 1902, p. 673.
20. v. Kahlden. — "Ueber die sogenannte Apoplexia Uteri,"
Ziegler's Beitr., 1898, vol. xxiii., p. 161.
21. Ketffer. — " Histology of the Nervous System in the Uterus,"
Bull, de la Soc. Beige de Gyn. el d'Obst., vol. xi., No. 5.
22. Klob. — " Pathol. Anat. der weiblichen Sexual-organen,"
p. 173.
23. Kustner. — " Die Behandlung der post-partum Blutungen,"
Deut. med. Woch., 1890, p. 5.
24. Lofqvist. — "Zur Pathologie der Mucosa corporis uteri."
Berlin, 1903.
25. Macgregor (Jessie M.). — " Pathology of the Endometrium,"
1905.
2G. Marchesk— Arch. d'Obst. et Gyn., 1897.
27. Martin. — Path, und Therapie der Frauenkrankheiten, vol. i.,
p. 994.
28. Meerdervoort (Pompe v.). — "Anatomie de la Pseudo-
endometrite," Bevue de Gyn,, 1902, vol. vi., p. 227.
29. Melnikow-Kaswendenkow. — Zieglers Beitr. zur path.
Anat. und allgem. Pathol., vol. xxvi.
30. Mullerheim.— "Arterioskleros. Uter.," Zeits. filr Geb. und
Gyn., vol. xxxvi., p. 355.
31. Pichevin et Petit. — " Metrorrhagies et lesions vasculaires
de Puterus," Gaz. Med. de Paris, 1895, p. 553.
32. Pick. — Volkmann's Sammhmg Minischer Vortrage, Nr. 283.
33. Pierra. — " Primary Uterine Congestion in neuro-arthritic
Patients," La Gyn., June 1904.
34. Pozzi et Latteux. — "Sur une forme rare de nitrite
hemorrhagique," Revue de Gyn., 1889, vol. iii., p.
771.
116 HEMORRHAGE AND ARTERIO-SCLEROSIS OF UTERINE VESSELS,
35. Eeinecke. — " Die Sklerose der Uterinarterien unci die
klimakt. Blutungen," Archiv fur Gyn., vol. liii., p.
313.
36. Richelot et Bakozzi. — " Scleros. uter. et la vrai metrite,"
La Gyn., Paris, 1901. .
37. Saville.— Brit. Med. Journ., 1896, vol. ii., p. 713.
38. Shaw (W. F.).— " Chronic Metritis : its Pathology and its
Relation to Chronic Endometritis," Thesis, Manchester,
1906.
39. Simmonds. — "Ueber Hamorrh. d. Endometr. bei Sklerose
der Uterus-arterien," Centralbl. filr Gyn., 1901, No. 3,
p. 81.
40. Siredey (A.). — "La metrite parenchymateuse chronique,"
La Gyn., Feb. 1902, p. 1.
41. Theilhaber. — "Die Ursachen der praklimakterischen
Blutungen," Archiv filr Gyn, 1901, vol. lxii.
und Meier. — " Die Variationen, im Bau des Mesome-
trium, etc.," Archiv filr Gyn., 1902, vol. lxvi.
"Die sogenannte chronische Metritis, etc.," Archiv
filr Gyn., 1903, vol. lxx.
42. Westphalen. — " Zur Physiologie der Menstruation," Archiv
filr Gyn., vol. Hi., p. 35.
43. Wittek (Kurt). — " Die sklerotischen Gefassveranderungen
des Uterus, etc.," Monats. filr Geburts. und Gyn., 1906,
vol. xxiii, p. 796.
The President conveyed to Dr Macdonald the thanks of the
Society for bringing this piece of work before them. Her paper
was a most thorough, a most scientific, a most academic dis-
cussion of the subject. It was a difficult subject, and Dr
Macdonald had tackled it in a thoroughly scientific way. It was
also a difficult paper for them to discuss, because the questions
raised in it were, many of them, novel and somewhat complex.
BY DR ELIZABETH H. B. MACDONALD. 117
It seemed to him that, apart from the purely scientific way of
presentation, the practical view came to be that the uterus at
the menopause became very rapidly old; that the uterus, so
to say, might be 70 while the patient herself was still between
40 and 50; and that in the ageing of the organ the vessels
might become old before the rest of the uterus. It occurred
to him that it might be found that the same sort of changes
occurred in the placenta in cases of accidental haemorrhage
where there was no traumatism. It would be a very good sup-
plement to her work to compare this condition in the uterus
with a placenta of that kind. He himself thought that in
looking over these microphotographs, he had seen sections of
placentae that closely resembled them.
Dr Haultain seconded the President's eulogy on the very
excellent paper which Dr Macdonald had given them. The
subject was very wide, and one they could not discuss in its
entirety. There were one or two important practical points
which had been brought before them. In the first place, there
could be no doubt that haemorrhages from the uterus might
be threefold — endometric, ovarian, and from the uterine wall.
The endometric variety, which they all knew so well, with the
capillary changes and so on, and which naturally could be cured
in the majority of cases by curetting. It was perhaps with the
other two varieties that the paper dealt more particularly.
With regard to the ovarian variety, there was no reasonable
doubt that the ovary had a strong influence on uterine haemor-
rhage. From time to time they met with cases in which the
ovary and it alone was the cause of uterine haemorrhage. Some
years ago, before hysterectomy was such a common operation,
the removal of the ovaries was undertaken for severe intractable
cases of haemorrhage for which curetting would not do any
good. It struck me that in several cases bleeding still continued
after the removal of the ovaries ; although in the majority of
cases monorrhagia and metrorrhagia frequently were cured by
118 HAEMORRHAGE AND ARTERIOSCLEROSIS OF UTERINE VESSELS,
the removal of the ovaries, which made it certain that there
was an important ovarian influence. But it was in these cases
where, after the removal of the ovaries the bleeding continued,
in which there was some condition in the uterine wall, or the
vessels penetrating that wall, which gave rise to the condition.
He had had upon five occasions to remove uteri for that condition,
where there was no malignancy, where the ovarian condition,
as far as one could see, was perfectly normal, but where in
spite of persistent curetting, and in one case in spite of the
removal of the ovaries, the bleeding had continued. Three of
these cases were in young women under 25. In the other
two cases the women were well past the menopause. The
condition found in four of these was almost identical — a
very considerable arterio- sclerosis, and in three of these very
considerable thickening of the uterine wall, analogous to that
found in so-called fibroid and in subinvolution. Further, in
making some investigations in fibroids, one found in a consider-
able proportion of fibroid uteri, that this condition of the blood-
vessels existed. It seemed to him that possibly this accounted
for those cases where, after the removal of the ovaries, there was
still bleeding from a fibroid uterus. Post-climacteric haemorrhage
could go on in a uterus already afflicted with fibroid disease.
There was certainly a class of case where nothing but removal
of the uterus could cure the condition, which might be not
only post-climacteric, but might occur in a very young woman.
And it seemed to him a far better operation in young women
in whom curetting did not cure the condition, and where the
patients were invalided, to remove the uterus and leave the
ovaries, than to remove the ovaries and leave the uterus;
because in the former cases the ovarian influence was not
removed, and the removal of the uterus itself did not seem to
act in the same way as removal of the ovaries, for it was an
organ which did not appear to have an internal secretion.
Dr Ritchie said he had listened with very great interest to
BY DR ELIZABETH H. B. MACDONALD. 119
the paper. Dr Macdonald's opinion seemed to him to be that
the arterio-sclerosis was practically a physiological change in
aged uteri, and that haemorrhage did not arise quite so much
from changes in the vessels as from what was behind them.
He asked Dr Macdonald to state in her reply whether this was
the opinion which she advocated.
Dr B. P. Watson said he could not offer the explanation Dr
Fordyce desired. As to the particular uterus which Dr Barbour
had described and which he had had the pleasure of examining,
the vessel changes in it were very much the same as Dr Mac-
donald had described. The vessels of the mucous membrane
were specially affected, and showed great thickening of the walls
and hyaline degeneration. There was no arterio-sclerosis of
any other vessels, and no history of any cause likely to produce
the condition. One ovary was cystic, but no other abnormality
was present. He said the paper had been a most interesting
one, and the microphotographs shown were very clear, so that
he would have liked to have seen the actual sections, which
must be very fine.
Dr Porter said he was not competent to discuss the paper,
but expressed his pleasure at having heard it read. He
inquired whether there was any history of haemophilia in any
of the cases.
Dr Elizabeth Macdonald, in reply, thanked the Fellows for
the way in which they had received the paper. In reply to Dr
Eitchie, she said she did take up the attitude that the vessel
changes were of secondary importance in the causation of
haemorrhage. She had come to this conclusion from a con-
sideration of the case of premature senile change, where the
vessels were extensively degenerated, and where there was no
haemorrhage to speak of. As to septic infection causing the
vessel changes, there was no doubt that it was one of the most
general causes of vessel degeneration. But in the case quoted
the patient had suffered from monorrhagia for ten years, and
120 EXHIBITION OF SPECIMENS, ETC.
the infection had been quite a recent one, not lasting for more
than three months, so that it could not in this case explain
the monorrhagia of twenty years' standing.
Meeting IV. — February 9, 1907.
Dr J. W. Ballantyne, President, in the Chair.
I. The following ladies and gentlemen were elected Ordinary
Fellows of the Society:— Mary C. Hamilton, L.R.C.P. & S.E.,
L.F.P.S. Glas., Sick Children's Hospital, Edinburgh ; Elsie M.
Barnetson, M.B., Ch.B., 31 Morton Street, Joppa ; J. A. MacLeod,
M.B., Ch.B., Royal Maternity Hospital, Edinburgh ; H. S. Reid,
M.B., Ch.B., Royal Maternity Hospital, Edinburgh.
II. The President showed — (a) A PAIR OF cystic kidneys
from a foetus. There had been some difficulty with the labour,
and the child was still-born. Only a very rapid post-mortem
examination was permitted, and the liver and both kidneys were
found to be enlarged. The kidneys only were removed; each
weighed over 4 ounces, and one was 10 cm. long and the other
9 \ cm. — about three times the normal size. There was not very
much to be made out on naked-eye examination, save a general
spongy appearance, but under the microscope the kidney tissue
was seen to consist of hundreds of thousands of small cystic
cavities. These kidneys are supposed to be not really cystic,
but a form of adenomatous degeneration, and so are really to be
classed as tumours rather than cystic degenerations, (b) Frozen
sections of A female fcetus, born in Maternity last September.
At birth it was thought to be normal, but when Dr Ballantyne
was going round the ward the next day he noticed that the
child was carrying its head very low on its shoulders, and
STUDY OF THIRTY CERVICAL FIBROIDS. 121
ventured a diagnosis of cervical spina bifida, though there was
no external indication thereof. It died in a few days, and the
specimen showed very well the condition of hidden cervical
spina bifida.
III. Br Barbour showed — (a) A fibrous tumour of ovary,
so wedged in pelvis and pressing against uterus that a diagnosis
of uterine tumour was made. There were pressure symptoms on
the rectum, and there was difficulty at the operation in pulling
the tumour past the promontory. (6) Euptured ovarian cyst,
with pseudo-myxoma peritonei. The cyst contained gelatinous
material. The omentum was hanging down like an apron,
infiltrated with this tissue, (c) Dermoid tumour of ovary,
with a twisted pedicle. The tumour had been diagnosed as a
fibroid of ten years' duration, and during that time it had not
produced any symptoms. The patient was suddenly seized
with symptoms partly suggestive of torsion of the pedicle, but
instead of sickness there were symptoms of obstruction of the
bowels, which was found on operation to be due to paralysis
of the bowel, the result of commencing peritonitis. There was
difficulty in overcoming the paralysis of the bowel for two or
three days, but the patient did very well.
IV. A CLINICAL AND ANATOMICAL STUDY OF THIRTY
CERVICAL FIBROIDS REMOVED BY ABDOMINAL
HYSTERECTOMY.
By F. W. N. Haultain, M.D., F.R.C.P. Ed., Physician for Diseases of
Women, Deaconess Hospital, Edinburgh.
As is well known, the cervix and body of the uterus essentially
differ in their anatomical aspects from the earliest periods of
the development of the organ. These striking differences they
maintain throughout the life of the individual, not only in
122
STUDY OF THIKTY CERVICAL FIBROIDS,
their anatomical, but also in their physiological and pathological
features. Upon such it is not necessary to dwell, except in the
essential particular which is associated with the development
and growth of uterine fibro-myomata, which forms the text of
the following observations.
The development and growth of these tumours in the
cervix is rare, and is said to account for about 5 per cent, only
Fig. 1.
of all cases of uterine fibro-myomata. In this connection my
operative experience is not in strict accord, as out of 260 cases
of hysterectomy for these neoplasms, I have on thirty occa-
sions met with their primary development in this situation.
But when the large number of corporeal fibro-myomata I have
seen, in which operative treatment was unnecessary, is con-
sidered, this percentage may fairly be taken as about the
normal. At the same time, it must be remembered that
BY DR F. W. N. HAULTAIN. 123
submucous cervical fibroids aud interstitial tumours of the
intravaginal portion are by no means rare, and are removable
through the vagina.
Divisions of Cervix. — To study and classify these growths
one must take into account the anatomical description of the
cervix into three portions — supravaginal, inter vaginal, and
intravaginal, which is of such great importance in the descrip-
tion of hypertrophic conditions. These may be described as
being differentiated from one another by the attachment of the
vaginal walls ; the " intra " being below the attachment of the
anterior vaginal wall, the " supra " being above the attachment
of the posterior wall, and the " inter " the intervening portion
between these two (Fig. 1). Tumours of the intravaginal
portion alone do not here call for description, as their removal
by the abdominal route, or indeed the removal of the
uterus, is uncalled for, and they may thus be dismissed. I
therefore confine myself to those associated with the intervaginal
and supravaginal portions with subsequent involvement of the
intravaginal portion.
1. Table of cases in which cervix alone ivas involved —
(a) Supravaginal portion . . {^fir' 1} 4]
(b) Supravaginal and intervaginal /Posterior 4\ A^
portion [Anterior 2|
(c) Supravaginal, intervaginal, /Posterior sl-.^
and intravaginal portions (Anterior 4 J -
2. Cases complicated with corporeal fibroids . 7 7
3. Case complicated with one month's pregnancy 1 1
30
The supravaginal tumours were more of the subperitoneal
type, and, with one exception, grew from the posterior wall,
and embedded themselves downwards in the recto-vaginal
septum. They thus bulged the posterior vaginal wall forwards,
124
STUDY OF THIRTY CERVICAL FIBROIDS,
but in no way affected the free portion of the cervix, except
that it was displaced high up behind the pubis, and was diffi-
cult to reach.
Six supravaginal and intervaginal growths were met with,
two in the anterior and four in the posterior wall. As the
result of the want of involvement of the intravaginal portion,
the external os was in no way affected, and remained as a
slight projection on the base of the tumour, with a small open-
ing at its tip (Fig. 2). All these tumours were sufficiently
Fig. 2.— Fibro-myoma involving supravaginal and intervaginal portions of cervix
anterior wall. Dotted line shows peritoneum.
large to fill the brim of the pelvis, and grew upwards and
downwards, assuming the typical ovoid shape. The bladder in
all instances was displaced upwards into the abdomen — in the
anterior tumours by the actual growth itself, and in the
posterior by the stretching of the anterior wall. In each the
growth was incarcerated in the pelvis, and, as might be
BY DR F. W. N. HAULTAIN. 125
expected, gave rise to well-marked pressure symptoms, particu-
larly associated with micturition.
The entire cervix was involved in twelve instances. In
eight the growth developed in the posterior wall, in four the
anterior wall. In these cases, through the stretching and
thinning of the uninvolved cervical lip, the os externum was
much dilated, and easily admitted the tip of the finger.
All were sufficiently large to fill the true pelvis, and thus
conformed to the typical ovoid shape, as in the previous
tumours.
The disposition of the peritoneum is of interest, as it
naturally is varied according to the position of the tumour in
the anterior or posterior wall. When anterior, the retro-
uterine pouch is in no way interfered with, and the peritoneum
extends downwards over the upper third of the posterior
vaginal wall; while in the posterior tumours the peritoneum
is lifted up over the top of the growth, and thus separated
from its usual relations to the vaginal roof. In the latter
instances the tumour occupied the recto-vaginal septum, and
was in close apposition to the rectum and vagina, a relation of
very considerable importance with regard to operative removal
(Fig. 3). When anteriorly situated, the peritoneum along with
the bladder is lifted high in the abdomen, and separated from
the anterior abdominal wall for a considerable distance.
In all of the cases but one the growths were uninodular,
although in eight instances they were associated with fibro-
matous nodules in the uterine body. In the multinodular
growth which grew from the anterior wall, and involved the
entire cervix, the displacement of the surrounding organs was
extreme. The bladder was drawn round to the right side of
the pelvis, while the fundus uteri was displaced into the retro-
uterine pouch. The entire brim of the pelvis was filled by
the tumour, and the usual landmarks were thus completely
obliterated (Fig. 4).
126
STUDY OF THIRTY CERVICAL FIBROIDS,
Clinical Features. — As might be expected from the situation
and size of the tumours, intrapelvic pressure symptoms were
mainly in evidence. These in the majority of instances were
associated with the functions of the bladder, mainly in the
direction of retention of urine. Firstly, this was complained of
at or about the menstrual period, when the tumour was tem-
porarily engorged, but later it occurred at other times ; and in
Fig. 3.— Unencapsulated cervical fibroid of posterior wall involving entire cervix. Dotted
line shows peritoneum and obliteration of retro-uterine pouch.
one instance it was permanently present; here the irregular
pressure on the base of the bladder continued to make cathe-
terisation difficult, as from the prolonged distension of the
bladder it remained atonic and pouched, so that unless the
catheter actually passed into the upper diverticulum only
partial evacuation was procured. Pain, as the result of
pressure on the pelvic nerves, is, strangely enough, not a
BY Dll F. W. N. HAULTAIN.
127
marked symptom ; it is by no means so evident as in incar-
cerated fibroids of the body. Haemorrhage was a most unequal
symptom, and in only ten of the twenty-two cases could be
considered severe; seven of these being instances where the
entire cervix was involved. In eight there was neither
monorrhagia or metrorrhagia.
It is probable in some instances the haemorrhage was
increased by some attempt at the expulsion of the tumour
Fro. 4.— Fibro-myoma involving the entire cervix. Small nodule in uterine body.
below the mucosa. In this type not only is there a special
disposition towards haemorrhage, but also a tendency to slough-
ing and gangrene, probably due to some impairment in the
blood supply. Haemorrhage must not, therefore, be considered
a constant symptom, although frequently present.
In my own experience, in only two instances did the
tumour show any signs of degeneration. These were oedematous
128 STUDY OF THIRTY CERVICAL FIBROIDS,
and gangrenous. In a case, however, of Professor Simpson's, in
which I had the honour of assisting him in its removal, a large
central degeneration cyst was present, similar to those met
with in the so-called fibro-cystic myomata of the uterine body ;
the contents were spontaneously coagulable on evacuation.
Operation. — The operation for the removal of these growths,
though by no means simple, does not present the formidable
difficulties which from their situation one would anticipate, as
they are usually readily enucleated from their surroundings.
Perhaps the most troublesome difficulties are the absence of the
usual landmarks from the displacement of the surrounding
structures, the close relation to the ureters, and the inability to
recognise the elongated and stretched uterine arteries. In one
case, where the tumour arose from the anterior lip and filled
the brim of the pelvis, incarcerating the retroverted fundus with
the ovaries in the pouch of Douglas, and pushing the distended
bladder far round to the right side, when the abdomen was
opened nothing but a large indefinite mass could be seen, which
required to be enucleated from its subperitoneal bed before the
true relation of parts could be made out (Fig. 4).
As might be expected, the incision in the vaginal wall is
preferably to be commenced anteriorly after stripping the
bladder down. In a typical case, the following may be described
as the method of operating. On opening the abdomen, the
small uterine body will be seen situated on the top of the
growth. This is laid hold of by a pair of strong vulsella and
forcibly pulled upwards. The infundibulo pelvic ligaments are
tied and the broad ligament cut. The round ligaments are
similarly dealt with. In anterior growths, the loose peri-
toneum covering the tumour is then incised from pelvic wall
to pelvic wall anteriorly, and, with the bladder, is freed from
the mass ; this is usually easily accomplished, but care must
be taken not to tear through the large plexus of vesical
veins, which may cause most troublesome haemorrhage. The
BY DR F. W. N. HAULTA1N. 129
uterine arteries are now ligatured as low as possible and
divided.
An opening is then made into the anterior vaginal fornix.
This is enlarged laterally, extending round the tumour mass,
the vaginal wall being gripped in small sections by forceps
before cutting. By this means, bleeding from the vaginal
arteries, wherever present, is controlled, and they can be easily
detected and tied.
When the growth is from the posterior wall, the loose
peritoneum covering is incised in like manner and the tumour
enucleated from the rectum and its bed, care being taken to
keep close to the tumour laterally to avoid the ureters. After
enucleation, the anterior vaginal vault is opened and the tumour
removed by a process similar to that in the anterior growth.
After all vessels have been tied, the bed of the tumour is
packed with gauze and the end drawn down into the vagina.
The two layers of the peritoneum are now stitched completely
over the gauze by continuous thin suture in Lembert fashion.
The gauze is withdrawn after forty-eight hours, by which time
all oozing has been controlled. The vagina is then gently
syringed out daily with warm sterilised water. In supravaginal
growths, after enucleation the remaining portion of the cervix
is cut across and treated by the subtotal method.
In posterior growths, the close connection of the tumour to
the rectum from which it has practically been stripped, forms a
distinct sourcef of danger, in so far as the bed of the tumour
may subsequently become infected by the Bacillus coli directly
from the bowel. In three of my cases this complication
occurred, and in two of these it proved fatal. It is well, there-
fore, in these instances to see that the bowel is not only freely
evacuated but cleansed by means of weak antiseptic enemata.
In cases where there is a distinct muscular capsule to the
growth, it is undoubtedly safer to incise it transversely from
side to side at the same level as the peritoneal incision, and
I
130 STUDY OF THIRTY CERVICAL FIBROIDS,
proceed to enucleate the tumour' from the capsule. The cavity
which remains is then packed with gauze and the end drawn
through the vagina; by this means there is no baring of the
rectum, and the risks of infection from this source minimised
(Fig. 5).
Fig. 5.— Uterus and posterior cervical fibro-myoma removed, the latter enucleated
from its capsule.
In these cases the tumour may be enucleated after vertically
splitting the uterine body and thus reaching &ie bed of the
tumour from above. This is the method adopted by Bland-
Sutton and Eutherforcl Morison. A distinct capsule, however,
is not always present, and complete removal is essential.
The combination of large corporeal and cervical fibro-
myomata is, fortunately, rare, and the difficulty and danger of
their removal is very great. Personally, I know of no operation
in gynaecology which offers so great difficulties, from the want
of definite landmarks and the distortion of surrounding im-
BY DE F. W N. HAULTAIN. 131
portant organs. Each case seems more puzzling than the other.
The dislocation of the bladder and ureters, the splitting of the
layers of the mesosigmoid, and the want of room to work from
the incarceration in the true pelvis, all tend to prevent con-
ventional method of action and demand originality.
Perhaps the most interesting of these it has been my fortune
to meet was the removal of the specimen I show of combined
fibroid and pregnancy five months, in which labour was present.
I have, unfortunately, to record three deaths in the thirty
cases operated upon, a mortality of 10 per cent., which un-
doubtedly compares most unfavourably with my experience of
hysterectomy for corporeal fibroids, which shows a mortality of
slightly more than 1 per cent.
That the operation is legitimate, however, even with such
results, there can be no gainsaying, as the symptoms present in
all cases were severe and dangerous, and doubtless would
shortly have caused the death of the individual, a very different
status from the victims of corporeal fibroids, in whom the
operation is undertaken for discomfort and semi-invalidism, and
the life of the patient is only threatened in a comparatively few
instances.
Two of the deaths occurred in posterior cases, and were due
to septic infection; this was probably predisposed to by the
large area of enucleation, which involved baring the rectum.
In these cases, therefore, I now always, if possibly, enucleate
from their capsule, so that stripping from the rectum may be
avoided. The third death was also due to septic infection from
a sloughing cervical tumour associated with a large corporeal
growth.
The President said they had listened with the greatest
interest and pleasure to Dr Haultain's paper. It was only
after seeing a great number of cases that one was able to
132 STUDY OF THIRTY CERVICAL FIBROIDS,
make out the small points of difference that existed, more
especially with regard to the relationship of parts to other
organs, and the relation of the tumour to the uterus itself.
Dr Haultain's communication had greatly cleared up the
topography of these cervical fibroids, and would enable them in
the future to classify them into anterior and posterior
varieties, and according to the three segments of which the
cervix is composed. The deductions from such topographical
knowledge were very interesting with regard to treatment, and
to the close proximity of the rectum. He had wondered
when Dr Haultain was describing his cases, whether there had in
any case been any infection of the tumour itself from the
rectum. His own personal operative interference with cervical
fibroids was limited to two cases : one which he had enucleated
from the cervix, and in which he had had to face tremendous
haemorrhage at the time ; and the second, in which he had done
a pan -hysterectomy. Both cases had made a good recovery.
In both of them the tumour had affected the intravaginal
portion, and had been anterior also in both cases. Certainly,
he thought that Dr Haultain's paper showed that with very
few exceptions it was a very risky thing to approach these
growths through the vagina, and that abdominal hysterectomy
was the right thing to do. He was sure the Society was much
indebted to Dr Haultain for bringing the cases forward in such
a masterly way.
Dr Barbour said that the President had touched on most of
the points he had intended to refer to. He congratulated Dr
Haultain on the clear and lucid description of these tumours in
respect to the parts of the cervix from which they grew, and
with regard to the displacement of the peritoneum. It was a
very interesting fact that tumours growing from the cervix
posteriorly lifted the peritoneum up, and that the pouch of
Douglas was displaced to such a height. Dr Haultain had
drawn attention to the interesting fact that usually the fibroid
BY Dli F. W. N. HAULTAIN. 133
tumours of the cervix were single — that is to say, that one did
not often see a fibroid of the cervix and several of the uterus ;
and, indeed, that one might almost assume that a cervical
fibroid will be a single tumour, although now and again there
were exceptions. For that reason he wondered whether one of
the tumours figured was a cervical fibroid. It seemed to
extend a good way up into the anterior uterine segment, and
to be as much a uterine as a cervical tumour. He wished to
ask if there was any liability to kidney complications in any of
the cases ; and to Dr Haultain's reply in the negative, he said
it was interesting that although there must be considerable
pressure on the ureters, yet there was no disturbance from the
kidneys. Dr Haultain had brought out an interesting and
important point with regard to the operation — in regard to
leaving the capsule in the case of any tumour that comes to be
in relation to the rectum. In olden days the operation of
enucleation was a dangerous one for the patient, and to have
left a portion of the capsule behind, would have been con-
sidered to have increased the risk of the operation. But it was
now evident that if the tumour was thoroughly cleaned out, it
was quite safe to pack with gauze, and that with good drainage
from below, the risk of infection was less. He looked on the
paper as a very important contribution, not only to the topo-
graphy of the tumours, but also as to the operative treatment,
and was in a line with the splendid work Dr Haultain had
already done on the subject.
Dr Brewis said that he had listened with the greatest
pleasure and with considerable profit to the very valuable paper
of Dr Haultain. Dr Haultain had treated the subject so fully
and dealt with it in so admirable a manner, that there was very
little left to say. His experience of this class of case accorded
entirely with that of Dr Haultain, with one exception. He
had thought he had met with all possible varieties of
cervical fibroids, but he found he had not mot with two of the
134 STUDY OF THIRTY CERVICAL FIBROIDS,
examples that Dr Haultain had figured. He said there was
really nothing to criticise, though he would state his experience.
As to the frequency of cervical fibroids, his experiences coin-
cided with that of Dr Haultain. In 10 per cent, of the
cases requiring abdominal section he had found cervical fibroids.
Dr Haultain had classified the tumours into the usual divisions
of the cervix. He thought they might also be designated as
submucous, interstitial, and subserous. With regard to
symptoms, every cervical fibroid was more or less intrapelvic,
and when growing big enough gave rise to pressure symptoms.
The outstanding, and frequently the only symptom, was reten-
tion of urine. He was accustomed to tell his students that if
a non-pregnant patient above a certain age came complaining of
retention of urine, almost certainly she had a fibroid tumour,
and in nine cases out of ten it would be a cervical fibroid. He
had also met with haemorrhage in some of his cases, and in such
the tumour had usually been of the submucous variety. As to
the treatment of these tumours, the various anatomical features
they presented required different technique. They had to
avoid the bladder in front, the rectum behind, and the ureters
at the side. He had had several cases of cervical fibroid that
had been limited entirely to the supravaginal portion of the
cervix, and each case had been done by the supravaginal opera-
tion. In one case the tumour had grown backwards, and
opened up the meso-rectum, and was very difficult to remove.
He had had a number of cases similar to the ones represented
— subserous cervical fibroids growing either from the anterior
or posterior aspect. In these cases, after having opened the
abdomen and divided the peritoneum, he had shelled the
tumour out of its capsule, put stitches into the bed of the
tumour, and drained per vaginam, closing the abdomen without
removing the uterus. He had done this in subserous tumours,
growing both from the anterior and posterior aspect of the
cervix. Submucous or interstitial differed quite from that
BY DR F. W. N. HAULTAIN. 135
variety. They formed a more or less elliptical tumour. If
large, they filled up the whole pelvis, and were very difficult to
remove; because, as Dr Haultain pointed out, the uterine
vessels were spread out alongside, elongated, and difficult to
ligature. From want of room it was also difficult to avoid the
ureters. He had removed at least six of such cases by pan-
hysterectomy, much as described by Dr Haultain. In a
number of cases he had found that this operation was simpli-
fied by splitting the uterus; after having divided the broad
ligaments as far down as possible, and pushed down the bladder,
he had split the uterus down vertically from the fundus, and
enucleated the tumour. Enucleation might be difficult, and
not safe to practise. In such a case, even without enucleation,
the splitting of the uterus and tumour was of the greatest
service, because one can pull up one half and ligature the
vessels, and then do the same on the other side ; it was then a
simple matter afterwards to open the vagina. Enucleation was
of the greatest benefit, not only in cervical fibroids, but also in
corporeal fibroids. In the most difficult cases, where some-
times one did not know where one was, one could incise and
get a blunt instrument between the capsule and the tumour
and shell it out, and might shell out several in that way.
After that was done, that which had been very complicated
became quite simple. He cited one remarkable case in which
the patient had come to him after the eighteenth operation.
He was told that each time she had presented herself previously
to her doctor, there was a fibroid at the vagina, and that several
inches of it were removed. When the patient came under his
care for the nineteenth operation, he had removed the whole
uterus. Dr Haul tain's paper was one of the greatest value,
and perfect in all its details, not lending itself to any criticism.
136 HYSTERECTOMY FOR FIBROID TUMOURS IN PREGNANCY,
V. HYSTERECTOMY FOR FIBROID TUMOURS IN PREG-
NANCY. TWO CASES.
By A. H. F. Barbour, M.D., University Lecturer on Gyniecoloiry.
The interesting paper by Dr Brewis on two cases of pregnancy,
complicated by fibroid tumours, treated by hysterectomy, read
at the December Meeting of our Society, induces me to place on
record two cases of operation for similar conditions, performed
during the last few months. These cases differ from those
recorded by Dr Brewis in that the operation was done at an
earlier period, when it was not a question of Cesarean section.
Under the rarity of the condition I may mention that these
are the first cases that have come under my notice in connection
with my experience at the Eoyal Infirmary, which extends now
over many years. The clinical histories of these cases are as
follows : —
Case I. Fibroid Tumour of Cervix. — After five normal
pregnancies and labours patient became pregnant, and had
repeated haemorrhages during pregnancy, followed by a natural
labour at term. Eighteen months later an abortion at the sixth
month, the haemorrhage during the pregnancy preventing her
knowing her condition until abortion occurred. A year later,
after four months' amenorrhoea, a tumour the size of a foetal
head discovered in the pelvis, growing from the posterior lip of
the cervix and displacing the uterus upwards. Pan -hysterec-
tomy a fortnight later. Eecovery.
Case II. Fibroid Tumour of Posterior Wall of Uterus. — An
abortion at the third month, a year after marriage. Eight
months later became pregnant again ; and now, after four and a
half months' amenorrhoea, has a uterine fibroid about 4 inches
in diameter to the right, displacing pregnant uterus to the left.
DY DR A. H. F. BARBOUR. 137
The tumour has a broad base of attachment, and has rotated
the uterus, so that the right appendages lie anterior. As
patient desired immediate operation, supravaginal hysterectomy
was done. Eecovery.
A comparative study of the cases raises the following
interesting questions.
As regards the situation of the tumour and the consequent
displacement of the uterus, we note that the cervical fibroid
measures 4J inches transversely, 2| vertically, and 3 antero-
posteriorly. It springs from the posterior half of the cervix,
its attachment extending up into the lower uterine segment.
It is a single tumour, there being no other in the uterine wall.
It must have been present for some time, as fibroid tumours of
the cervix do not grow rapidly ; indeed we have evidence of its
presence as far back as 1903, when the patient had her sixth
child. The repeated haemorrhages in pregnancy in a patient
who had had five previous normal pregnancies point to the
development of this tumour, although it was not of sufficient
size to interfere with her sixth labour. Her seventh pregnancy
was also marked by haemorrhages, so frequent that the patient
was unaware of her condition until a sixth month's foetus was
expelled prematurely.
It is an interesting fact that conception occurred with a
tumour which, making allowance for its more rapid growth
during the early months of pregnancy, must have been of
considerable size. This shows that the sterility characteristic
of these tumours is not due to their bulk, but to associated
changes in the uterine mucosa.
Another interesting question is how far the patient was
gone in pregnancy. She gave a history of four and a half
months' amenorrhoea, and of having felt foetal movements for
six weeks, that is from the third month onwards. The fundus
stood about 1 inch above the umbilicus. At first I was inclined
138 HYSTERECTOxMY FOR FIBROID TUMOURS IN PREGNANCY,
to think that she was only four and a half months pregnant,
and to attribute her having felt foetal movements from the
third month to the fact that the tumour in the pelvis, displacing
the uterus upwards, had brought it into contact with the
abdominal wall at an earlier period than is usually the case.
From the size of the uterus, however, and especially the length
of the foetus, which measures 13 inches, it is evident that the
pregnancy is of five and a half months' duration. In this case,
what she described as her last menstruation must have been
a haemorrhage some weeks after conception.
The second case shows a fibroid tumour of the posterior
wall of the uterus, measuring about 4 inches in diameter, and
with a broad base of attachment extending from the level of
the Fallopian tubes to the lower uterine segment. Before
operation it looked is if we had to do with a tumour attached
fco the right side of the uterus, displacing the pregnant uterus
to the left ; on abdominal section, however, it was found that
the tumour had caused rotation of the uterus, so that the right
uterine appendages were opposite the abdominal incision.
From the size and position of the tumour, delivery of a child,
in the event of pregnancy going on until the child was viable,
could only have been possible by Csesarean section.
These cases also raise the interesting question of the reasons
for operative interference, and whether immediate operation was
necessary. In the case of the cervical fibroid the appearance
of the part of the tumour presenting at the vulva decided the
question. The tumour was undergoing infection, and though
there was no temperature it was evident that it would not be
safe to allow pregnancy to go on in the hope of getting a living
child. Even had the tumour not been undergoing necrotic
changes it would have been a doubtful policy to temporise,
because labour had come on prematurely in the previous
pregnancy ; and to defer operation until labour was advanced
would have greatly increased the risk to the patient. The
BY DR A. H. F. BARBOUR. 139
dilatation of the cervix seen in the preparation shows that as a
matter of fact labour had already begun, though no pains had
been noticed, before the patient was on the operating table.
The necessity for immediate operation was not so obvious
in the second case. Although it is doubtful whether pregnancy
would have gone on until a viable child could have been
obtained by Cesarean section, yet, had there been an opportunity
for keeping the patient under observation, the operation might
have been deferred. In forming an opinion in a case of this
nature one has to be guided by the patient's wishes, and had
she been anxious to run a certain amount of risk for the
possibility of having a living child, I should have advised delay.
Both the patient, however, and her husband wished to have as
little risk as possible, and requested immediate interference.
With regard to the operation itself, little requires to be said.
In the first case pan-hysterectomy was performed, care being
taken to prevent infection of the peritoneal cavity as the
tumour was lifted out of the pelvis. In the second case supra-
vaginal hysterectomy was performed, the cervix being left.
In both cases I was struck by the fact that the operation of
hysterectomy is not made more difficult by the existence of
pregnancy. While more ligatures are necessary to control
venous haemorrhage, the stretching of the peritoneum and
opening out of the ligaments, resulting from the pregnant
condition, facilitates the dealing with bleeding points and the
covering over of the pelvic floor with peritoneum. Both
patients made an excellent recovery.
140 EXHIBITION OF SPECIMENS.
Meeting V. — March 13, 1907.
Dr J. W. Ballantyne, President, in the Chair.
I. Dr Brewis showed — (a) a four months' fcetus (extra-
uterine) removed by vaginal section, and A portion of the
placenta. The patient was aged 35 ; had had five children, the
youngest of whom was five years old ; the last period was on
21st October, the operation on 22nd February. The primary
rupture took place on the eighth week, as far as could be ascer-
tained, for she had been seized at that time with severe pain in
the lower abdomen, resembling the pains of labour ; the pains
were not followed by any collapse. The vomiting and pain
had continued till the time of operation. On examination the
whole of the lower abdomen had been found to be distended
with a tense swelling, not firm and resistant, but more like an
ovarian cyst. Towards the symphysis, and in the left iliac
region, there was distinct resistance and dullness on percussion.
Per vaginam, the uterus was found to be enlarged and pushed
to the front by a tense cystic swelling, filling up the posterior
part of the pelvis. The diagnosis of tubal rupture of an extra-
uterine gestation was made. He had operated from below, as
was his custom in most of these cases. The patient was very
feeble ; haemoglobin 50 per cent. ; and he had carried out venous
transfusion while the patient was getting the anaesthetic. He
had opened through the posterior fornix opening into the
sac, from which had poured fluid which looked like liquor
amnii. He got hold of a foot of the infant and delivered
rapidly, and had taken away a piece of the placenta and
blood-clot. The fcetus was living at birth; the cord was
attached to the upper part of the sac ; in the left iliac region
was the rest of the placenta, but he had not considered it wise
to remove the placenta from that site. The sac was packed
with gauze (16 yards were used). The rupture had been
between the layers of the mesometrium, the embryo and
EXHIBITION OF SPECIMENS. 141
membranes had escaped into the portion of the pelvis uninjured,
and the pregnancy had continued. As the sac enlarged, it lifted
up the peritoneum from the anterior surface of the rectum and
the anterior abdominal wall, and the explanation of the vomit-
ing was that the pregnancy had continued — it was the vomiting
of pregnancy. He took it that the sac was in imminent
danger of undergoing secondary rupture. He pointed out
the advantage of operating from below;, for if this had been
opened from the front he would have encountered the placenta
first, and the patient would have succumbed to any operative
procedure from above. But from below the operation had
been easy and comparatively safe. The placenta had not yet
come away, but was coming away in pieces, and the patient
was doing quite well.
(&) Large subperitoneal fibroid, showing mucoid degenera-
tion, with a very small pedicle.
(c) Cervical fibroid, growing from the anterior wall of the
cervix, and removed by pan-hysterectomy.
(d) Two dermoids removed from the same patient, who
was married and had had a large family.
(e) Double pyosalpinx, removed by the operation of
hystero-salpingo-oophorectomy — it was a tuberculous case.
The tube had ruptured at the time of operation, and pus
escaped over the field of operation; but the patient had
recovered without a bad symptom — the pus being sterile.
(/) Ovarian tumour, from a patient who had been operated
on by Thomas Keith, nineteen years before. It was a case in
which Keith had evidently not thought it wise to remove the
whole tumour, and had stitched the cyst-wall to the abdominal
wound, leaving a portion of the tumour. When the case came
under his care, the tumour had filled the greater part of the
abdomen, and was attached to a large surface of the anterior
abdominal wall. The tumour had been removed by taking away
a great part of the anterior abdominal wall.
142 EXHIBITION OF SPECIMENS.
IT. Dr Haig Ferguson showed — (a) A pelvic abdominal
tumour from patient set. 38, diagnosed as uterine fibroid,
producing severe oedema of right lower extremity from pressure
upon right external iliac vein. This was practically the only
symptom caused by the tumour, as the patient had no metror-
rhagia, no severe menorrhagia, and only a copious watery
intermenstrual discharge. The specimen showed — (1) large
submucous fibroid ; (2) fibroid which was removed from
between the layers of the right broad ligament, and which was
continuous with the submucous fibroid. Apparently the
tumour commenced interstitially, and grew simultaneously
outwards between the layers of the broad ligament and in-
wards as a submucous fibroid, the two portions being united by
a narrow neck. Pressure symptoms were completely relieved
by operation.
(b) Pelvis of primipara, who was unconscious from acute
eclamptic toxsemia at full time, with strong labour pains, and
demanding rapid delivery. Head lay persistent occipito-
posterior, and was not engaged at the brim. Forceps proved
unavailing, and as child was dead, craniotomy was performed.
Patient never regained consciousness. The measurements of the
pelvis were : — Interspinous, 9 \ inches ; intercristal, 9 £ inches ;
conjugata vera, 3 J inches; conjugata diagonalis, 3f inches;
transverse (widest point), 5 J inches, (available), 4 J inches;
left oblique, 4J inches; right oblique, 5 inches; cavity fairly
roomy; transverse at outlet, 4J inches. Projecting into the
lumen of the brim opposite the right iliac pectineal eminence
was a spinous process, causing shortening of left oblique
diameter by J inch, as compared with right. Type: — The pelvis
was apparently a justo-minor, complicated with rickets. It
seemed to be after the type described by Litzmann, in that it
had an ungainly and angular appearance, and in the marked
prominence of the pubic crests. There was a slight scoliosis.
The head lay in the RO.P. position, the occiput becoming
EXOPHTHALMIC GOITRE. 143
impacted on the abnormal spinous projection on the right ilio-
pectineal line — a fact which could be easily made out during the
conduct of the labour, and necessitating craniotomy. Un-
fortunately, the birth of the foetus did not modify the toxaemic
condition, the fits continuing, and the patient dying in toxsemic
coma.
III. EXOPHTHALMIC GOITRE IN ITS RELATION TO
OBSTETRICS AND GYNECOLOGY.
By Sir J. Halliday Croom, M.D., Professor of Midwifery in the
University of Edinburgh.
The relationship of exophthalmic goitre, known as Graves'
disease or Basedow's disease, to pregnancy, parturition, and to
various forms of gynaecological disease, has received compara-
tively little attention in this country, and as I have observed a
number of cases within recent years, I venture to record some
conclusions I have arrived at, although I fear in the main they
are negative.
It is unnecessary to describe the symptoms characteristic of
this disease, nor in a short paper can I deal with the theories as
to its etiology. Suffice it that amongst many supposed causes
brought forward by various authorities we find changes in the
blood, changes in the heart muscle, enteroptosis, floating kidney,
auto-intoxication from digestive disorders, impairment of the
lymphatic circulation, changes in the ganglion cells of the cortex,
changes in the medulla, lesions of the sympathetic, lesions of
the restiform bodies, and finally hypersecretion of the thyroid
gland.
This last point, the question of the thyroid, is an extremely
difficult and important one. Eichardson, whose essay on the
subject is classic, says that the spontaneous enlargement and
hypersecretion of the gland is more than improbable; and
144 EXOPHTHALMIC GOITRE,
Gibson, in his able and valuable paper on "Adaptation and
Compensation," condemns non-functional hypertrophy in any
part of the human organism in characteristic language as "a
base figment of the imagination."
As we shall see later, there seems to be a direct relationship
between pregnancy and the thyroid, a point to which attention
has been drawn recently by the researches of Nicholson and
others into the connection between eclampsia and the thyroid
gland. And if we consider the undoubtedly close connection
between the thyroid and metabolism and assimilation, we must
at least admit the plausibility of Thomson's claim that the causa
causans is a toxaemia, and that this produces a perversion or an
increase in the quantity of the thyroid secretion. It is certain
that pathologically the changes which take place in the thyroid
gland are usually a parenchymatous hyperplasia with changes
in the colloid material and degenerative changes in the
protoplasm and nuclei. There is, however, no definite
histological change in the organ that can be called specific
of exophthalmic goitre, and all the above changes may be found
in patients who present none of the symptoms of Graves'
The disease is, roughly speaking, ten times more common in
women than in men. This I take to be an undisputed fact.
But, judging from the statistics of my own hospital work, which
has been entirely confined to the Maternity Hospital and the
gynaecological wards of the Koyal Infirmary of Edinburgh, it
would seem to be a comparatively rare condition associated
either with pregnancy or uterine affections. At all events,
looking back over my work in the Maternity Hospital, and
going over the statistics of the hospital, which include 15,000
cases, I have only met with one case in which there was any
reference made to goitre, and in that case there were neither
tremors nor exophthalmos. During the fifteen years in which I
had charge of the gynaecological ward in the Eoyal Infirmary, I
BY PROFESSOR SIR J. HALLIDAY CROOM. 145
met with only two cases of exophthalmic goitre which were
associated with uterine affections ; to these I shall refer later.
I have occasionally seen cases of exophthalmic goitre in associa-
tion with my colleagues in the ordinary medical wards of the
Royal Infirmary, but in these cases, except irregular menstrua-
tion, there was no affection of the genital organs whatever.
It must therefore be apparent that the disease must be more
common in the better classes than amongst those who attend
hospitals; and from all that is known of its etiology, this is
just what one would expect of a disease arising, as it does very
often, after shock and mental anxiety in highly strung nervous
systems.
When regard is had to the age at which exophthalmic goitre
is most prevalent, we find that it coincides with the active
period of uterine life. Taking a table from Murray's most
interesting paper, I find that the youngest case was 15 years old
and the oldest 65. The most common period lay between 16 and
35, but quite a number occurred between the ages of 40 and 50,
a period coinciding with the normal changes which take place
in the genital system at the menopause.
That there is a relationship between the generative apparatus
and the thyroid, there can be no question. My experience
entirely coincides with that of Martin, whose extremely able
and interesting paper has just been published, that a great many
girls suffering from exophthalmic goitre have special discomfort
during menstruation, and I have noticed that the thyroid gland
enlarges in some cases at the same time. It is not necessary,
nor in my experience is it common, to have pathological con-
ditions of the pelvic viscera associated with exophthalmic goitre.
It seems to me that the periods when exophthalmic goitre is
most likely to be developed or exaggerated, are the three epochs
when the generative system is at the height of its activity, — at
puberty, at menstruation, and during pregnancy. May I quote
a sentence from Martin's excellent work: "Growth is more
K
146 EXOPHTHALMIC GOITRE,
active than ever at the age of puberty, and with the onset of
activity of the generative organs the vitality of all parts of the
organism is raised, and the glands involved in the metabolism
are put to an unprecedented strain; especially is this so in
the female sex."
The question of the condition of the thyroid during preg-
nancy has received a very considerable amount of attention.
That there is a greater or less increase of its volume during
pregnancy seems to me to be beyond dispute, and that it
gradually disappears after delivery is an ascertained fact.
Freund it was who first systematically examined the relations
between the thyroid gland and the female genitals. He arrived
at the conclusion that the relation occurs not through the
nervous system but through the blood. Heidenreich was of
opinion that the pregnant uterus hindered respiration, and
thus led to an accumulation of blood in the gland. The general
opinion, however, seemed to be that the enlargement was
sympathetic. Such was the way the question stood when
Lange approached the subject, and in a very interesting and
original paper discussed the matter, taking his statistics from
observations made by himself from October 1893 to January
1898. The result of his examinations very much corroborated
those of Freund, and he found that a hyperplasia of the
thyroid was an almost constant concomitant of pregnancy. Lange
made his observations most carefully, eliminating all apparently
obvious causes leading to mistake. It is, for instance, the
tendency of many pregnant women to put on fat, and therefore
he only took women with thin necks, so as to make no possible
error ; and, furthermore, in measuring the neck after accouche-
ment, especially after tedious labour, he only did so after
twenty-four hours, as the neck is apt to be turgid and swollen
immediately after labour.
The important conclusion he arrived at was that hyperplasia
of the thyroid is a physiological appearance in pregnancy, and
BY PROFESSOR SIR J. HALLIDAY CROOM. 147
that in the majority of cases it begins about the sixth month,
and ceases at an indefinite period after labour. He points out
that with kidney affections peculiar to pregnant women there
is no hyperplasia, and in an able paper by Nicholson, this
matter is very fully discussed. Upon this matter I have no
intention of entering to-night.
Considering, therefore, the frequency with which this
disease occurs ; considering, further, the fact that it occurs in
women during the active period of menstrual life; consider-
ing, further, the intimate connection which apparently exists
between the thyroid gland and menstruation and pregnancy —
one would naturally expect to have exophthalmic goitre more
commonly associated with uterine conditions than seems to be
the case.
Kleinwachter, in his work published in 1890, paid particular
attention to the relationship between the sexual organs and this
disorder, pointing out that in many cases the sexual develop-
ment was wanting. In the case which he particularly described,
there was a loss of the hair ; the mammary glands were atrophied,
almost completely so; the mons veneris was poor in adipose
tissue and destitute of hair ; the labia were flabby, especially
the minora ; the vulva was gaping ; the whole vagina was loose,
with slight prolapse of the anterior vaginal wall; the portio
vaginalis was scarcely the size of a kidney bean; the uterus
was sunk down, the cavity was small, with the walls very thin
and flabby; both ovaries were small and tender. These
changes, in fact, entirely correspond with senile marasmus.
Similar changes in the sexual sphere were noted by Mobius and
Cheadle.
Cholmogoroff records a case as follows : — A woman, ret. 32.
Eight previous full-term labours, last in November 1892. Well
built ; moderate development of subcutaneous fat ; no exopthal-
mos ; slight tremor of the hands ; frequent and severe attacks
of palpitation, which had existed before marriage, and had
148 EXOPHTHALMIC GOITRE,
been explained by the doctor as due to anaemia. There was
considerable increase of the thyroid gland. This increase in
the thyroid was noticed in the fourth pregnancy. The gland
gradually grew larger with each pregnancy. Patient's mother,
set. 60, had a large goitre, and a sister a smaller one. In the
mother and sister there were no symptoms of Graves' disease.
The patient came under Cholmogoroff's care owing to a
bleeding of three weeks in connection with an incomplete
abortion. The breasts atrophied in spite of the pregnancy;
before this the breasts had been well developed. In the end of
1893, there occurred a tenth pregnancy, resulting in abortion.
The symptoms became worse in each succeeding pregnancy.
Jouin refers to a connection between the menopause and
Graves' disease. He observed in forty-three cases that the
uterine lesion preceded the Graves' disease. Improvement in
the local condition, he avers, is always accompanied by improve-
ment of the general condition.
Doleris, on the other hand, believes that the treatment of
the uterine disease might cure women having tachycardia
simulating Graves' disease, but in the case of those having true
exophthalmic goitre it would be imprudent to promise to cure
them of their goitre by treatment directed against their uterine
disease.
In those cases that have come under my own observation,
I have only met with abnormality in the sexual organs in three
cases.
Case I.— Sent to me by Dr Haggart of Aberfeldy. The
patient had well-marked exophthalmic goitre. She was sent to
my care specially because she was suffering from profuse
menstruation and recurrent attacks of retention of urine.
On examination, a fibroid tumour was found blocking up
the pelvis. On placing the patient under an anaesthetic, she
expired at once, before she had been touched with a view to
BY PROFESSOR SIR J. HALLIDAY CROOM. 149
operation. This case is particularly interesting to me, as it is
the only case that I ever lost under the administration of an
anaesthetic. Unfortunately, no post-mortem was permitted.
Dr Luke, the anaesthetist to the Eoyal Infirmary, informs me
that exophthalmic goitre is one of the most trying cases with
which an anaesthetist has to deal. They are in many ways
worse than a simple goitre or Derbyshire neck, as, owing to the
extreme nervousness of the patient and the great vascular
excitement, the conditions favouring sudden cardiac failure are
present in a marked degree, and conditions are not improved by
the possible, and indeed probable, narrowing of the air- way by
the thyroid growth. Such cases he would place, as far as risk
is concerned, alongside of aortic aneurysm, and bad cases of
mitral stenosis and tricuspid regurgitation.
Case II. — A single lady, aet. 50, with extremely marked
exophthalmic goitre, with profuse haemorrhage almost con-
tinuous. She had a large ovarian tumour on tha right side,
and a polypus projecting from the cervix. She had been
practically bedridden for two years, as much owing to the
Graves' disease as to the haemorrhage.
I first of all removed the polypus, and sometime afterwards
performed ovariotomy. She made the usual recovery, and at
the end of a month left the Home. It is interesting here to
observe the fact that six months afterwards the goitre had very
considerably diminished, and the exophthalmos, tremor, and
tachycardia were very much better. At the end of three years,
although still an invalid, and unable to support herself by her
own exertions entirely, the symptoms were very much
ameliorated.
Case III. — One of the most interesting cases I have met
with, was that of a girl with well-marked exophthalmic goitre,
150 EXOPHTHALMIC GOITRE,
who had reached 20 years of age and had not menstruated.
It was for the local condition she was brought to me. On
examination, I found that the amenorrhea was due to an
imperforate condition of the hymen, which was bulging, and
there was a distinct tumour on the right side suprapubically.
She had had regularly for years back the usual monthly dis-
comfort, but no haemorrhage at all. I treated the case in the
usual way, and she made an excellent recovery. There was no
marked change in the condition of the exophthalmic goitre.
I saw her ten years after that, and she still suffered from
invalidism, due to her tremors and tachycardia.
I have no record of any special abnormality in the sexual
organs of those cases where the disease occurred in young
single women, except that, in the majority of cases, the tendency
was rather to menorrhagia than to amenorrhea. In one only,
after the continuance of the disease for some years, amenorrhea
became developed. But as the girl's emaciation was extreme,
and no obvious benefit was to be got from local examinations,
none was accordingly made.
On the other hand, I have seen two girls in whom the
disease developed just after puberty. Neither girl menstruated
until she was about 20, and then only scantily. Both married,
and were sterile. On examination, I found an infantile
condition of the pelvic organs.
Kleinwachter refers to two cases in young women, in the
first of which menstruation was retarded and scanty ; and in
the second case the menstrual period lasted six weeks.
Hoedemaker records the case of a young woman, set. 29,
who had suffered from exophthalmic goitre for two years. In
her he found changes similar to those that describe the
climacteric.
Bamour also records a case in which the uterus was atro-
phied, and the ovaries and tubes not palpable.
On the other hand, in my experience I have found, as I
BY PROFESSOK SIR J. HALLIDAY CROOM. 151
have said, that menorrhagia is the symptom when the disease
is early and progressive, and amenorrhoea only pronounced
when the disease is far advanced, or when it occurs very
early in puberty.
With regard to the occurrence of the disease in older
unmarried women, I have had occasion to examine ten such.
In not one of these ten cases have I found anything abnormal,
except irregular and, for the most part, profuse menstruation.
I am driven to the conclusion, therefore, that in many cases
recorded, the atrophy of these organs was due more to the
psychic effect than to any result of the actual disease, mental
shock being, as I have already said, a very frequent cause of
this condition. Nothing is more common than to find that the
menstrual function is disturbed by psychic and mental con-
ditions, and to these I attribute the amenorrhoea rather than to
the existence of the disease itself.
Furthermore, it must be kept in view that in a large number
of the cases recorded the amenorrhoea and atrophy were the
consequences not of the disease itself, but of its exhausting
influences and long duration.
Out of fifteen cases occurring in women under 30 years of
age, which have been under my own observation, or have been
seen with others, where a local examination was made, no
apparent lesion of the pelvic organs could be discovered. An
interesting point is that there was no record of any dysmenor-
rhea, and that the condition of the flow was rather increased
than otherwise.
So far as the histories of my cases are concerned, the onset
in every one had followed more or less nervous shock. One
specially interesting case was that of a girl, set. 26, who, in
addition to well-marked Graves' disease, had profuse menstrual
discharge, and at the same time had monthly attacks of mania
coincident with her menstruation, so bad that on several
occasions she had to be confined in the padded ward in hospital.
152 EXOPHTHALMIC GOITRE,
In this case, after consultation with my colleagues, I removed
her ovaries, with a view first of all of controlling the haemor-
rhage, and secondly, in the hope that the removal of the ovaries
might also have the desired effect upon the mania. I heard
from her regularly for two years after the operation, and she
remained free of the maniacal attacks during that time, but her
condition of exophthalmic goitre remained unchanged, although
the menopause had been completely established.
Sanger reports three cases of women he examined with this
disease. In one case there was amenorrhoea, which Sanger
explains as lactation amenorrhoea. The uterus was not atro-
phied.
In the second case the menses were somewhat scanty, but
this Sanger attributes to the approaching climacteric and the
marked adiposity of the patient. In this case also the uterus
was not atrophied.
In the third case the woman was pregnant.
In these three cases, therefore, Kleinwachter's contention
that this disease is associated with atrophy is not borne out.
On the other hand, some, like Caracoussi, have described several
cases where there has been atrophy of the mammae.
Therefore, from my own experience, as well as from the
records of the cases that have been reported, especially abroad,
I must arrive at the conclusion that there is no interdependence
between pelvic disease and Graves' disease, because the same
conditions, such as fright, or mental shock, which would
precipitate Graves' disease, would at the same time affect the
pelvic organs as well.
With regard to the effect which pregnancy has on exoph-
thalmic goitre and vice versd, as I have already pointed out,
this disease is practically unknown in the Maternity Hospital
in Edinburgh, and therefore the records of the cases which
occurred under my charge are all from my private case book.
I have myself observed twelve cases of exophthalmic goitre
BY PROFESSOR SIR J. HALLIDAY CROOM. 153
during pregnaucy, with the following results. In all of them
the condition as to eyes, thyroid, and heart was very marked.
It would extend this paper beyond due limits were I to record
these cases in detail ; enough for me to say that in eight of the
twelve the course of pregnancy was unaltered, and the delivery
was uncomplicated, and, so far as I was able to judge, the
affection in each of those eight cases was aggravated for a time
after the labour was over.
Of the four remaining cases, in Case L, the patient, set. 30,
had post-partum haemorrhage, so profuse as to require the
uterine cavity to be plugged. She recovered slowly from her
haemorrhage, and afterwards suffered from superinvolution of
the uterus. The labour took place eight years ago, and she has
not menstruated since, and the uterus and ovaries remain small
and atrophied. The exophthalmic goitre, though somewhat
modified, is still sufficiently marked to make her an invalid.
In this case I attribute the atrophy of the uterus and ovaries to
the excessive haemorrhage.
The second case was seen with the late Dr Duddingstone
Wilson. A lady, set. 34, five months advanced in pregnancy of
a third child. AVell-marked exophthalmos; the thyroid very
considerably enlarged ; pulse 140 per minute ; marked tremors ;
profuse perspiration. I was asked to see the case because of
some haemorrhage; diagnosis, accidental haemorrhage; treat-
ment, as the haemorrhage was slight, palliative. The symptoms
of exophthalmic goitre had been present for six months before
her present pregnancy, and had been induced, as she believed,
by a fall from a dogcart. Previous to that accident, she had
been in good health, rather robust ; since then she had become
emaciated until the occurrence of the present pregnancy, when
her symptoms became slightly aggravated, until during the past
five months she had become very much emaciated, and been
unable for her household duties. As the haemorrhage increased
very markedly, it was determined to terminate the pregnancy,
154 EXOPHTHALMIC GOITRE,
and this was done by dilating the cervix and turning. The
placenta was found in its normal situation, the haemorrhage was
comparatively slight, and the patient recovered very slowly
from the immediate interference.
In Case III., I was asked to see a patient, set. 29, pregnant
of a first child three months, because of symptoms of miscarriage.
When I saw her she had well-marked exophthalmic goitre, the
exophthalmos being very pronounced, and the goitre but slight.
The pulse was 130 per minute, and the tremors, though present,
were not striking. The miscarriage, when I saw it, was inevit-
able, the os being open and the ovum protruding. I therefore
emptied the uterus, and although every precaution was taken,
the haemorrhage was so profuse that she was reduced to pro-
found anaemia, and remained in bed for three months. During
this time, although the lines of treatment were mainly those of
anaemia, and no special treatment was given for the exoph-
thalmic goitre, yet in the course of the three months her
symptoms of exophthalmic goitre very much diminished; the
exophthalmos was less pronounced, and the pulse fell to under
100. It is well worthy of notice that in this particular instance
the result of the profuse haemorrhage was that the patient
developed superinvolution, and that there was no menstruation
again for twelve months afterwards.
I saw Case IV. only after delivery was over, and that because
of a severe convulsion three hours after delivery. The con-
vulsions occurred at varying intervals, and with increased
rapidity, until the patient died during an attack. She had had
during the whole of her pregnancy and for a year before, well-
marked exophthalmic goitre, with the usual group of symptoms
of exophthalmos, goitre, tremqrs, and tachycardia.
There is no lack of cases recorded showing that pregnancy
considerably favours the formation of this disease. There are
also many cases recorded by others which show that pregnancy
often makes this disease considerably worse. Considering the
BY PROFESSOR SIR J. HALLIDAY CROOM. 155
high degree of susceptibility of the nervous system, and the
well-marked hydrsemia and anaemia characteristic of pregnancy,
results such as this are what one would expect.
In a recent paper, Wilson of Birmingham records eight cases
of exophthalmic goitre in pregnancy which had come under his
notice. In only two did menstruation continue normal. In
two there was monorrhagia, in four there was more or less
amenorrhea, and in one of these there was premature atrophy
of the sexual organs.
Trousseau and Charcot taught that pregnancy had a favour-
able influence on exophthalmic goitre, but they were unaware of
the fact that the thyroid gland enlarges during pregnancy in
the normal condition. Bucquet, again, on examination of
twenty-one cases, arrived at the conclusion, first of all, that
exophthalmic goitre can be provoked by pregnancy at a date
more or less remote from confinement. The cases he quotes,
however, are very uncertain, and his conclusions very indefinite.
Further, he points out that when exophthalmic goitre occurs
previous to pregnancy, the influence exerted by the pregnancy
upon the goitre is very uncertain ; in his own words, it may be
"either neutral, benign, or aggravated." He further quotes
three cases, two of which seem accurate, that pregnancy may
transform simple goitre into an exophthalmic goitre; and of
the ten cases in which pregnancy occurred during exoph-
thalmic goitre, one was unaltered, three were aggravated, and
six were improved. He arrived at the conclusion, therefore,
that amelioration of the symptoms is to be expected when
pregnancy occurs in a woman suffering from exophthalmic
goitre. But his conclusions must be taken with a certain
amount of reservation, because at least seven of the cases which
he quotes were complicated by typhoid fever.
A more recent contribution to the subject is that of Audebert
of Paris. He records a case in which the disease developed in
the seventh month of pregnancy. There was a goitre and
156 EXOPHTHALMIC GOITKE,
exophthalmos, as well as much anasarca and scanty urine.
Delivery was followed by partial recovery, although the tremors
and exophthalmos persisted. Audebert is inclined to look
upon the disease in this case as a manifestation of the auto-
intoxication of pregnancy. While a conclusion cannot be
deduced from one case, the theory is interesting and suggestive,
in view of our increasing knowledge of the complex relation-
ships of the thyroid in pregnancy.
To bring the whole matter to an issue, it seems to me that
the conclusions to be arrived at are as follows : —
First, that exophthalmic goitre is a comparatively frequent
disorder of women.
Secondly, that the thyroid is enlarged during pregnancy.
Thirdly, that exophthalmic goitre and pregnancy are a very
rare combination, as shown by the fact that out of 15,000 cases
I have not met with one in hospital practice, and with only
twelve in private and consulting practice.
Fourthly, that the influence of pregnancy upon exoph-
thalmic goitre is very uncertain, and that in the majority of
cases it aggravates it.
Fifthly, that the effect of exophthalmic goitre on pregnancy
is practically nil ; and that, so far as my observations and those
I have collated from other sources abroad go to prove, most
pregnancies complicated with exophthalmic goitre follow a
regular even course ; and that of the accidents that occur, the
most frequent is haemorrhage, and occasionally abortion.
Sixthly, that the relation between pelvic disease and exoph-
thalmic goitre is rare, and that the effect of exophthalmic goitre
on the reproductive system is in recent cases to cause irregular
menstruation, mostly in the direction of monorrhagia, while in
very advanced cases it may cause amenorrhoea.
From these conclusions it must be apparent, therefore —
1. That girls suffering from exophthalmic goitre need nut
be precluded from marrying.
BY PROFESSOR SIR J. HALLTDAY CROOM. 157
2. That after marriage they need not be precluded from
pregnancy.
3. That if pregnancy occurs, there is no reason, except in
advanced cases, to interrupt the pregnancy, even in spite of the
fact that the children of women with exophthalmic goitre may
be expected, according to some authorities, to develop neuro-
pathic manifestations.
Bibliography.
Audebert. — Compt. rend. Soc. d'obst., de gynah et de pcediat. de
Paris, July 1906.
Bamour. — Centralbl.f. Gynah, Leipzig, 1891
Begbie. — Mori. Journ. Med. Sc, 1843.
Bucquet. — " Goitre exophthalmique et grossesse." Paris, 1895.
Caracoussi. — "Dissertation." Berlin, 1889.
Cheadle. — St George Hosp. Rep., 1878.
Cholmogoroff. — Monatschr. f. Geburtsh. u. Gynah, Berlin,
Bd. v.
Dol^ris. — Nouv. arch, d'obst. et gynah, Paris, 1895.
Freund. — Deutsche Ztschr.f. Chir., Leipzig, 1890.
Gibson. — Trans. Med. Soc. London, 1904, vol. xxvii.
Hodemaker. — Centralbl.f. Gynah, Leipzig, 1891.
Jouin. — Nouv. arch, d'obst. et gyn., Paris, 1895.
Kleinwachter. — Ztschr.f. Geburtsh. u. Gynah, Stuttgart, 1889;
Centralbl.f. Gynah, Leipzig, 1890; Ibid., 1891; Ibid,, 1892.
Lange. — Ztschr.f. Geburtsh. u. Gynah, Stuttgart, 1899.
Laycock. — Med. Times and Gaz., London, 1864.
Maude. — Practitioner, London, 1891.
Murray. — "Diseases of the Thyroid Gland." London, 1896.
Nicholson. — Edin. Med. Journ., August 1906.
Kichardson. — "Thyroid and Parathyroid Glands." Phila-
delphia, 1905.
Theilhaber— Arch.f. Gynah, Berlin, 1895.
Wilson.— Lancet, London, November 1906.
158 EXOPHTHALMIC GOITRE,
The President said that the Society had heard with great
interest the elaborate paper by Sir Halliday Croom. Although
the results were somewhat negative at present, still the facts
had been put before them in such a way that they knew what
they were, and could draw conclusions from them.
Br Barbour said the Fellows had to thank Sir Halliday very
much for bringing before them an important subject which, he
thought, did not lend itself very much to discussion. But the
paper was an important contribution to the subject on account
of its rarity. The importance of the condition had been
brought before him in connection with the literature of frozen
sections. In going into the cause of death in forty cases, one
of them (which had given them one of the most important
sections of the third stage) was from the sudden increase in the
size of a goitre, which caused death from asphyxia, the post-
mortem examination revealing that otherwise things were
normal. This showed that the presence of goitre might be a
serious condition in connection with the onset of labour, a
point which Sir Halliday had not referred to in connection
with his subject. It would be interesting to know whether
any facts would come out during the discussion, with regard to
its importance in connection with labour, for we would expect
occasionally to hear of complications in connection with labour,
even in the giving of the anaesthetic. Sir Halliday Croom's
conclusions, although negative, were very important, because he
thought that in the text-books it was stated that the presence
of goitre was a rather serious condition, and should be a contra-
indication to pregnancy. Edgar made as strong statements
regarding goitre, as in connection with heart affections, stating
that patients with Basedow's disease should not marry. It
would be reassuring to be able to tell patients that goitre in
pregnancy was not such a serious condition. As to the
gynaecological aspect of the question, the results there seemed
to be negative also. He thought Sir Halliday had shown
BY PROFESSOR SIR J. HALL1DAY CROOM. 159
that the occurrence of goitre with pelvic conditions must be
looked upon as a coincidence. He had himself had two cases
— (1) a patient with a fibroid tumour, who had been sent to him
for operation ; but the patient had a goitre without exophthalmos,
but of sufficient size to be a contra-indication to operation, and
he had sent her to Professor Chiene, who had removed the
goitre, and the patient had then returned to have the fibroid
removed. (2) The second case was one who had come for
a minor operation — the repair of the perineum. The condition
not being an urgent one, he had thought it better not to
operate. He thanked Sir Halliday for his very important
clinical contribution to the Society.
Br Brewis said he was sorry he was quite unable to discuss
the paper. All he knew of exophthalmic goitre in relation to
gynaecology and obstetrics, he had learnt that night. He had
great pleasure in expressing his admiration for the very able
and interesting paper that Sir Halliday Croom had given them.
He could recollect two cases of exophthalmic goitre occurring in
gynaecology. The patients were both young girls, and in both
of them there was menorrhagia. In one case there was a large
retroverted uterus to account for the menorrhagia, and in the
other a small intra-uterine polypus. These were the only
instances of exophthalmic goitre he remembered. He had
operated several times on patients with large goitres — removing
ovarian tumours and fibroid tumours, and had had no hesita-
tion— his only concern was with regard to the anaesthetic.
The conclusions Sir Halliday had drawn were of great value.
Br Ritchie had listened with very much pleasure to Sir
Halliday Croom's paper, and he was specially interested with
his conclusions. In relation to marriage, goitre stands in a
different position from Graves' disease. During pregnancy the
former would certainly become worse ; in Graves' disease the
result on the thyroid would be uncertain. Although Trousseau
and Charcot had recommended marriage with the expectation
160 EXOPHTHALMIC GOITRE,
that pregnancy would cure exophthalmic goitre, Trousseau had
later a somewhat sad experience of the effect of pregnancy on
that disease. Dr Kitchie was interested to note Sir Halliday's
experience of post-partum haemorrhage in Graves' disease,
because Lawson Tait's was similar. The etiology of exophthalmic
goitre was not known, but Sir Halliday had made a very strong
case for its being primarily nervous.
Dr Oliphant Nicholson said he had listened with great
interest to Sir Halliday Croom's paper. He had attended two
cases of pregnancy complicated by typical Graves' disease
during the last five years, both in multiparas, and both improved
markedly afterwards. With a disease like exophthalmic
goitre, which ran a very uncertain course, and which might end
in spontaneous cure in two or more years, it was difficult to
say at what stage of the disease pregnancy had supervened;
whether in the stage of progression, or at the stage in which
improvement was just setting in. In some cases the disease
might be apparently cured after pregnancy, but it was difficult
to say whether or not the cure was really due to the pregnancy.
In one of his cases, in the later months of pregnancy, the
tachycardia had improved very much, the size of the thyroid
had diminished a great deal, and all the symptoms became less
pronounced. In the puerperium things improved still more,
and later on the symptoms passed entirely away. This patient
had since been under the care of Dr Giles, and was regarded as
completely cured. The whole question of the influence of
pregnancy upon different diseases was a most interesting and
important one; pregnancy, undoubtedly, exerted a beneficial
influence on some diseases, and a baneful one on others. He
was strongly of opinion that the explanation of the different
effects produced was to be found in the manner in which the
condition of pregnancy modified the thyroid activity. As
regards labour in the cases mentioned, both were difficult.
He had not then known the dangers of chloroform in such
BY PROFESSOR SIR J. HALLIDAY CROOM. 161
cases, and had given a large quantity, and the patient had not
seemed any the worse for it. He wondered whether the
danger of anaesthetics in these cases was a mechanical one from
suffocation, owing to the size of the goitre, or whether there
was in this disease any special tendency to heart-failure. He
had had no special difficulty with regard to the breathing. In
both cases there was considerable post-partum haemorrhage in
the form of a steady oozing. This kind of haemorrhage was
what one might expect in cases of Graves' disease, owing to the
type of circulation present; characterised by a marked relaxa-
tion of all the smaller blood-vessels. Sir Halliday Croom did
not mention anything about the lactation in these cases; in
both his cases there had been a very great secretion of milk.
The connection between the thyroid gland and lactation was
very obscure, indeed the whole subject of the thyroid in relation
to pregnancy was so paradoxical, that at present one could draw
no definite conclusions at all. When thyroid was given to
nursing women it might increase the secretion of milk, and in
cows Hertoghe had shown that it acted as a marked galactagogue.
In myxcedema, even after the menopause was past, if one gave
very large doses of thyroid, it happened sometimes, as Bramwell
had recorded, that the breasts commenced to secrete milk
abundantly. On the other hand, in animals the mammary
gland sometimes secreted milk in large quantities after the
thyroid gland had been removed. This happened in a bitch
from which he (Dr Nicholson) had removed the entire thyroid
gland a year previously. This animal was not pregnant, and
yet the breasts became gorged with milk, and pups from
another bitch were suckled on two different occasions. In the
present state of our knowledge it was impossible to reconcile
such contradictory observations. It was a good thing that Sir
Halliday had brought up the subject of thyroid gland and
pregnancy, because it was one that gained every year in im-
portance, and seemed to have been much neglected in the past.
L
162 EXOPHTHALMIC GOITRE,
Dr Church was glad he had had the pleasure and honour of
hearing Sir Halliday's paper on this important subject. A few
years ago, on analysing 1000 cases of his own, he had come
across one case where exophthalmic goitre existed. It was in
the case of a lady's last pregnancy, and twins were born. He
thought the trend of the discussion had been to show that
pregnancy instead of increasing and aggravating the condition
seemed to be a curative agent. It was so in the case to which
he referred. Though the symptoms had been most marked
before pregnancy, she got almost entirely free of them after
the twins were born. One child had died ; the other, now aged
14 or 15 years, was subject to epilepsy, but that disease was
in the family. In regard to this far-reaching subject he had
thought it well to mention this case.
Dr B. P. Watson wished to mention a case under his care
of exophthalmic goitre associated with gynaecological disease.
There was monorrhagia, dysmenorrhea, and pain in the back.
There was marked exophthalmos, with a history of the patient
having become very nervous of late years, subject to frequent
sweatings, intermittent attacks of diarrhoea, and marked tremors.
In every way it presented the characteristics of exophthalmic
goitre. He had found that she had a large, tender, retroverted
uterus, which was rather fixed at the time of examination.
Under treatment the uterus had become smaller and movable,
and was replaced, and a pessary inserted, and from that time
onwards the symptoms of the exophthalmic goitre were less
marked. This was eighteen months ago, and now there was
only slight exophthalmos ; she was not nearly so nervous, and
was very much improved. She had had one child five years
ago, and no other since ; but whether the sterility was due to
the exophthalmic goitre or to the position of the uterus, he
could not say.
Sir Halliday Groom, in reply, said he had really no reply to
make. The only object of writing a paper was to record one's
BY PROFESSOR SIR J. HALLIDAY CROOM. 163
own personal experience so far as possible. And as he had had
the fortune to have some hospital appointments for some years,
he had thought it right to record the experience he had had.
He did not think it would serve any good purpose for him to
go over all the points suggested or spoken of that evening. He
thought he had referred to them all pretty fully in his paper.
He thanked the Society for the way it had received the paper.
Meeting VI.— May 8, 1907.
Dr J. W. Ballantyne, President, in the Chair.
I. The following gentleman was elected an Ordinary Fellow
of the Society:— A. M. Dick, M.B., Ch.B., Koyal Infirmary,
Edinburgh.
II. Dr Haig Ferguson showed — (a) uterus with adeno-
carcinoma of the body, removed from a woman, set. 42,
married, and with two children ; the patient was also the subject
of myxcedema. She had suffered from metrorrhagia for some
time, and after being curetted, the report of the pathologist was
that the condition was one of potential malignancy. He had,
however, no doubt from the clinical condition, and removed the
uterus per vaginam, because the patient was so very fat. He
thought the ovaries were also malignant, but the report upon
them was that there was a marked fibrosis, and no evidence
of malignancy. The special interest of the case was that it
was one of adeno-carcinoma in a muciparous woman.
(b) Extra-uterine pregnancy, removed from a woman
from whom four years ago he had removed the left Fallopian
tube for pyosalpinx, leaving behind the left ovary, because it
was so densely adherent. From the right side, at the same
164 Exhibition of specimens.
time, he removed the ovary for a small ovarian cyst about the
size of a tangerine orange, but had left the tube on that side.
Two months ago there were symptoms of extra-uterine preg-
nancy, and he had then removed the right tube with a tubal
pregnancy, in which there was an attempt at tubal abortion.
This was a distinct case of migration of the ovum. The left
ovary had ovulated, and the ovum must have found its way
into the right tube, though the migration was not a long one,
for the left ovary was prolapsed and adherent and close to the
right side.
(c) Double pyosalpinx, from a young lady recently
married. She had complained of abdominal pain, the result she
thought of a boxing match with her husband. On both sides
of the uterus were great masses, and distinct evidence of the
gonococcus was found.
III. JJr Haultain showed — (a) A fibeo-myoma of the round
ligament, 3 lbs. in weight, quite distinct from the uterus, (b)
Section showing tubercular endometritis, from a patient
who had complained of no symptoms. She had been recom-
mended to him on account of sterility. On examination, an
anteflexed uterus was found. There was a history of some slight
pain (heat the patient termed it) after making water. He
decided to dilate the cervix and curette, and the report of the
uterine scrapings was that it was tubercular. Then, upon
examining the urine, tubercle bacilli were found.
IV. Dr W. Fordyce showed — (a) carcinoma of the uterus
(three specimens — two cervical, one corporeal), removed by
vaginal hysterectomy; (b) uterus showing combined fibroid
TUMOUR AND CARCINOMA; (c) INTERSTITIAL FIBROID SHOWING
necrobiosis; (d) cervical fibroid tumour; (e) multiple
fibroids of uterus, removed for pressure symptoms; (J)
multiple fibroids, removed for post-climacteric haemorrhage.
EPILEPSY AND THE STATUS EPILKPTICUS.
165
V. EPILEPSY AND THE STATUS EPILEPTICUS IN CON-
NECTION WITH PREGNANCY AND LABOUR, WITH
ILLUSTRATIVE CASES.
By Robert Jardine, M.D., Professor of Midwifery in St Mungo's
College, Glasgow; Senior Physician to the Glasgow Maternity
Hospital.
In most works on midwifery the subject of epilepsy is dis-
cussed in a few sentences of general remarks. Again, in some
books on epilepsy, the effect of pregnancy and labour on the
condition is hardly mentioned. It is thus difficult to gain
information on the matter.
In his recently issued book on epilepsy, Dr W. Arden
Turner gives his experience of the influence of pregnancy,
the puerperium, and lactation in forty-one epileptic women, with
a history of sixty-one pregnancies. He tabulates the results in
the following way : —
Quickening induced a relapse in
P/egnancy was the original cause in
„ induced relapse in
„ was temporarily beneficial in
made no difference in
Accouchement was the original cause in
„ induced a relapse in .
Lactation was the original cause in .
„ induced a relapse in
7 cases.
2 „
14 „
6 „
1 „
5 „
17 „
3 „
6 .,
Total pregnancies
61
Forty-one cases. — Of twenty-five of these cases the family or
other history bearing upon heredity was studied, and thirteen
cases, or 52 per cent., gave a history of family epilepsy or
alcoholism, a percentage which corresponds with that ascer-
166 EPILEPSY AND THE STATUS EPILEPTICUS,
tained as the relative proportion of a family predisposition
amongst epileptics in general.
In the two cases where pregnancy was given as the original
cause, the women were both young, and pregnant for the first
time. In one of the cases where there was freedom from attack
in one pregnancy, the fits became more frequent in a second
pregnancy. He says: "There are undoubted cases on record
in which fits have been permanently arrested by pregnancy,
and others in which a temporary remission has been observed ;
but it will be seen from the figures here given, that it is more
common to find a relapse of the attacks, or the conversion of a
minor type of the disease into the combined major and minor
type. Nerrlinger's figures on this subject show that of ninety-
two women with one hundred and fifty-seven pregnancies, 28 per
cent, showed complete cessation of the fits during pregnancy,
and 35 per cent, were made distinctly worse."
In regard to accouchement and the puerperium, he says:
" There were five cases in which the disease clearly originated
at this time, and seventeen in which it led to a serious relapse.
Of the first series, the onset was in the form of serial epilepsy,
or the status epilepticus (puerperal eclampsia), and the disease
continued in a chronic form for many years afterwards. In
one case it commenced during the fourth confinement, and in
three others during the first. These cases are particularly
interesting, as they argue strongly in support of the view of
Fere, that puerperal eclampsia, like many other ' eclampsias,'
is merely epilepsy in an acute form, and that the disease, once
started in this way, may persist for years. Two cases were
illustrative of this, by the fact that after the original eclamptic
attack the further continuance of the malady was in the form
of minor seizures over a period of eighteen and ten years
respectively.
" Of the second series — those cases in which a relapse was
caused by confinement — there were two, in which a remission
BY PROF. ROBERT JARDINE. 167
of twelve and eighteen months respectively was broken by the
eclamptic seizures of the puerperium. In the others they
merely formed an incident in the course of the confirmed
disease.
"It was not uncommon, in cases of already existing
epilepsy, for puerperal convulsions to be delayed untiLthe later
pregnancies.
"The incidence of serial epilepsy, at or immediately suc-
ceeding parturition, is therefore a common feature in epileptic
women, and raises the question as to the diagnosis of some
forms of puerperal eclampsia. A history of pre-existing attacks
would determine the diagnosis of epilepsy ; while the existence
of a neuropathic family history, or the presence of stigmata of
degeneration, would point to eclamptic attacks as being of
epileptic nature. The presence of albuminuria does not of
necessity form the main element in the differential diagnosis, as
albumen has been found in the post-paroxysmal urine of
epileptics (Voisin and Peron), although it is not of common
occurrence.
" It is therefore clear that many cases of puerperal eclampsia
are really examples of serial epilepsy, or the status epilepticus,
induced during the puerperium in predisposed and neuropathic
persons."
I have given these long quotations from Dr Turner, as they
represent the views of a man who has had a very large
experience in epilepsy. With most of his statements I am in
agreement, but I cannot agree with the statement that many
cases of puerperal eclampsia are really examples of serial
epilepsy, or the status epilepticus. I have now seen consider-
ably over one hundred cases of puerperal eclampsia, and, before
the present series, there were only two which I considered
were really epileptic cases. In one of them there was no
albumen in the urine, and in the other there was a considerable
quantity, but in the latter case there was a distinct history of
168 EPILEPSY AND THE STATUS EPILEPTICUS,
previous epileptic seizures. The two conditions resemble each
other so closely that it is difficult to distinguish between them,
but there are so few cases of eclampsia which subsequently
have fits, even in connection with pregnancy, that I think we
are justified in concluding that a true case of puerperal eclampsia
is not one of epilepsy. It is impossible to follow up the sub-
sequent history of hospital cases, but in my private cases I
have not met with one in which epilepsy has developed. In
this connection it will be interesting to hear the experience of
others, and in that way we may get the results of a fairly large
number of cases.
Case I. — Mrs T., tet. 27, iii.-para, full time, was admitted to
the Glasgow Maternity Hospital on 27th February 1907, at
7.30 A.M., with a history of having had twelve fits since
4.25 a.m.
The patient's father died in an asylum, where he was confined
apparently on account of melancholia. Her mother is alive and
well. She had had seven sisters, one of whom died at the age
of 20, after having had epileptic fits for six years. The other
sisters are quite healthy, but one is very rickety. She had no
brothers. She had always been a healthy woman, and had
never had any serious illness. There was no history of any
injury and no evidence of syphilis. She had never had a fit
prior to the morning of admission.
The patient was married on 6th February 1903 ; her first
child was born in October of the same year, and the second in
June 1905. Both children were delivered with forceps at the
patient's home. She had had no miscarriages.
During the present pregnancy the patient's health had been
good. There had been no swelling of the face or legs, and no
headache until the evening before admission. On that evening
she had complained of headache, and had not felt well, but there
was no other symptom until she took the first fit at 4.25 a.m.
BY PKOF. KOBEliT JAKDINE. 169
On admission, the patient was quite unconscious, and had
several fits in the reception room before she was removed to
the labour ward. The fits were of the ordinary eclamptic type.
There was no cry at any time. The pulse was full and bound-
ing, and the respirations were hurried.
I saw the patient at 10 a.m., and up to that time she had
had twenty-one fits. She was at once put under chloroform,
and 16 fl. oz. of blood were drawn from a vein in the right arm,
and 3 pints of saline solution (1 dr. of sodium chloride and
acetate to each pint) were transfused. "While this was being
done, I found that the os was about half dilated, so I finished
the dilatation manually and delivered the child by version.
The uterus retracted well, but there was considerable bleeding
from the cervix, which had been lacerated bilaterally. After I
had allowed her to lose a good deal of blood I stitched the
cervix with catgut. The pulse remained fairly full and strong.
The delivery was finished at 10.45 A.M., and the patient was
free from fits until 6.20 p.m. (i.e., an interval of eight hours).
During this time she had been able to swallow 6 fl. oz. of milk,
3 fl. oz. of imperial drink, gr. viii. of calomel, and later a dose of
magn. sulph., and although she was not sufficiently conscious to
answer questions, she could be roused when spoken to. From
6.20 p.m. to 8.20 p.m. she had fourteen fits. A hot pack was
given at 8 p.m., and from 10 p.m. on the 27th until 3 a.m. on
the 28th (i.e., for five hours) she had no fits. At 11.15 p.m. an
intravenous injection of two pints of the saline solution was
given into the left arm. After midnight the patient perspired
freely. The pulse^rate had varied from 96 to 116, the tempera-
ture from 100*2° to 101 '4° R, and the respirations were 28.
The urine was found to be quite normal, without a trace of
albumen.
28th February. — The fits began again at 3 A.M., and she had
from four to seven per hour until 10.30 am. At 3.15 a.m. and
6.30 a.m. 30 grains of chloral and 60 grains of potassium bromide
170 EPILEPSY AND THE STATUS EPILEPTICUS,
were given per rectum. Part of the first injection was returned,
but the second was retained. At 1Q.30 A.M., an intracellular
injection of 2 pints of the usual saline solution was given
beneath the right breast, and the fits became less numerous.
At 12.45 an attempt was made to draw off some cerebro -spinal
fluid, but none could be obtained, although the needle was
inserted four times. Venesection was now performed in the
right arm and 9 fl. oz. of blood were withdrawn, and 2 pints of
saline solution, with double the quantity of sodium acetate,
were infused. The fits remained infrequent until 3 p.m., when
they again became more numerous and gradually increased in
number until she had thirteen between 8 and 9 p.m. In the
afternoon, between 3 and 5 p.m., three-quarters of a grain of
morphia was given hypodermically, in three doses, without the
least apparent effect on the fits. At 9 p.m., 30 gr. of chloral
and 60 gr. of potassium bromide were given by the rectum, but
the fits continued at the rate of twelve per hour. At 10.30
P.M., lumbar puncture was again tried, and at this time a little
over a fl. oz. of cerebro-spinal fluid was withdrawn. The fluid
was very slightly opalescent, but did not contain more blood
than could be accounted for by the puncture. A slight deposit
settled from the fluid, and this was found to consist of poly-
morphonuclear leucocytes with a larger number of lymphocytes
(small mononuclear leucocytes). The withdrawal of the cerebro-
spinal fluid did not produce any change in the patient's condition.
The fluid escaped from the needle by drops, except during the
fits, when it ran freely. Between the fits there did not seem
to be any increase in the tension.
After the fluid was withdrawn a dose of stovaine was
injected, and almost immediately there was a lessening of
movements in the legs during the fits, but the fits continued to
recur about every five minutes. In a few minutes there was
absolute paralysis of the lower limbs. The paralysing effect
spread up to the arms, and movement in them became much
BY PROF. ROBERT JARDINE. 171
less marked. The diaphragm was not affected. Shortly after
the stovaine had been administered, the movements, which had
all along been much more marked on the right side, now became
confined to the left side. In a short time the fits ceased to
affect the left side and returned to the right. The patient
became extremely collapsed, and the pulse disappeared entirely
from the wrist. Strychnine (^ gr.) was given hypoclermically,
and a pint of hot milk and 3 fl. oz. of brandy were injected into
the stomach through a tube. The pulse rapidly returned to the
wrist, but the patient remained collapsed for a considerable time.
1st March. — The patient remained in much the same con-
dition all day. The pulse kept remarkably good, the skin
acted well, the bowels moved freely, and plenty of urine was
passed, partly by catheter and partly unconsciously in bed.
The patient was fed at intervals with milk, water, and brandy
by the stomach tube. At 5.50 p.m. 2 pints of the usual saline
solution were infused into the abdominal walls, and at night
I gr. of morphia was injected subcutaneously. The fits occurred
at the rate of from six to fourteen per hour.
2nd March. — At 8 a.m. the fits became much more frequent,
and she had twenty between 8 and 9 A.M., and thirty between
9 and 10 a.m. ; the fits were slighter than on the previous days,
but the patient passed almost immediately from one to another.
The pulse was still remarkably good, but the patient's general
appearance was bad. The fits hardly affected the legs, and the
movements of the arms were not nearly so marked as during
the first two days. An attempt was made to examine the fundi
oculi with the ophthalmoscope, but nothing abnormal could be
detected except that the discs looked rather too red No optic
neuritis could be detected. The superficial layers of the cornese
were beginning to show evidence of destruction, and this, with
the continuous movements of the head, made the examination
very difficult. Between 12 noon and 1 p.m. the patient had the
greatest number of fits during any hour, viz., thirty-two.
172 EPILEPSY AND THE STATUS EPILEPTICUS,
At this time Mr Hogarth Pringle kindly saw the patient
with me, and we discussed the advisability of trephining, but
concluded that it would be of no avail.
From 6 p.m. the patient gradually sank, and she died at 7.40
P.M. without any other change taking place in her condition.
The rectal temperature taken immediately after death was
104-2° F. The number of fits recorded was 774.
The fits, though so numerous, did not appear to be very
exhausting. All along they were much more marked on the
right side than on the left, except for a short time after the
injection of the stovaine. As a rule, they commenced with
twitchings of both upper eyelids, especially of the right, followed
by conjugate deviation of the eyes to the right, the right arm
and right leg were then affected and the left side only very
slightly. During the tonic stage the patient did not become
so cyanosed as is ordinarily seen in epileptic or eclampsia
seizures, and she never gave a cry. The fits lasted from half a
minute to two minutes, and the tonic and clonic stages were of
much the same duration.
For the first two days no albumen could be detected in the
urine, and even later there was never more than a very faint trace.
Towards the end some finely granular tube-casts were found
on centrifugalising the urine. At no time did the patient
vomit, not even after the stomach tube had been passed.
There was some retching after a few of the fits, but that was
all. There was no jaundice. The knee-jerks were absent.
The highest temperature recorded was that taken, per rectum,
immediately after death, viz., 104*2° F. The skin acted well
during the whole of the last three days, and abundance of urine
was excreted. There was no oedema at any time.
The child, a male, was delivered by podalic version. It
weighed 7f lbs. At birth it was asphyxiated, but was easily
resuscitated. It remained, however, extremely blue during the
whole of the 27th February, and the colour never became quite
BY PROF. ROBERT JARDINE. 173
satisfactory, especially in the arms and legs. It lived three
days, and during that time its body was more or less in a state of
rigidity, the stiffness becoming much more marked at intervals.
It had many of these fits of rigidity, although there were no
convulsive attacks. At times the body assumed a position of
opisthotonos, and it could be lifted by placing one hand under
the head and another under the heels. When these fits of
rigidity came on, it gave a peculiarly distressing cry and then
became very cyanosed. It was very restless, and cried a great
deal. Its urine contained a considerable amount of albumen.
Chloral hydrate was given to it in grain doses every hour at
first, and finally every half-hour, and it gradually grew quieter,
but whether this was due to the action of the chloral or to the
increasing weakness it was impossible to say.
A post-mortem examination was performed on both bodies
by Dr Carstairs Douglas.
The Mother. — On exposing the dura mater a number of
small haemorrhages were seen, some punctiform and others
slightly larger, due to rupture of venules within the membrane.
The whole venous system of the membrane was engorged to a
striking degree, the engorgement being very evident in the
vicinity of the superior longitudinal sinus. The engorgement
was much more marked on the left side of the brain. The
meninges stripped off quite easily, and there was no evidence of
any thickening or of inflammatory adhesions. The brain sub-
stance was somewhat firmer than usual. No lesion could be
detected. About an inch of the upper end of the spinal cord
was removed, and it appeared to be quite normal.
Microscopic examination of sections from the motor area
showed that the nerve cells were normal. A small aneurismal
dilatation was observed on one of the minute arteries.
Thorax. — Both lungs were adherent and showed evidence of
old pleurisy. The lung tissue was fairly normal The heart
was normal except that the tricuspid valve was dilated.
174 EPILEPSY AND THE STATUS EPILEPTICUS,
Abdomen. — The liver showed a slight nutmeg condition.
The spleen was congested, pulpy, and enlarged. The kidneys
were both smaller than normal. The capsules stripped off
readily. The substance was pale and firm. The cortical area
in both was diminished in size. The uterus, ovaries, and tubes
were normal.
Microscopic examination of sections of the kidneys showed
evidence of acute nephritis. There were some haemorrhages
and blocking of the tubules with debris.
The Child. — The body was plump and well nourished. The
skull was harder than usual. The meninges were healthy. The
brain was soft and pulpy, and showed a fair amount of
vascularity, but not quite as marked as in the case of the
mother. There was no indication of haemorrhage in any part.
Abdomen. — The liver was of the usual size ; a little pale and
spotty in parts and engorged along the margin. The spleen
was of ordinary size and consistence. The kidneys were lobu-
lated and normal in appearance, but somewhat smaller than
usual.
Microscopic examination of the kidneys showed evidence of
congestion, but not so marked as in the mother's. There were
some haemorrhages, and some of the tubules showed exudate.
Remarks. — The differential diagnosis between epilepsy and
eclampsia is very difficult, and some alienists seem to think the
two conditions are identical. If there is a history of previous
epileptic seizures, I think one would be justified in looking upon
the case as epileptic. The condition of the urine will not be of
much assistance unless there is a large quantity of albumen in
it. I have never yet seen a case of eclampsia in which there
was no albumen in the urine. I am aware that such cases have
been recorded, but may not these have been cases of epilepsy ?
In the case just recorded there was no albumen in the urine at
the onset. At first I looked upon the case as an ordinary
BY PROF. ROBERT JARDINE. 175
eclamptic, but when I found there was no albumen in the urine,
and the fits began to recur, I concluded that we were dealing
with a case of epilepsy. Towards the end of the case there was
a trace of albumen in the urine, but that was what was to be
expected.
The status epilepticus is a condition seen frequently enough
in asylums. During a seizure the number of fits may be very
great. Dr Turner says that in a case of Leroy's there were 488
fits in twenty-four hours and 1000 in three days, and in a case
of Parsons' there were 1400 in four weeks. Turner has seen
2080 in eight weeks, 673 in ten days, 820 in five days, and as
many as 289 in twenty-four hours. In my case there were 774
fits in the eighty-eight hours from the onset until death, but
during fourteen of these hours the patient was free from fits, so
that the 774 fits occurred in seventy-four hours, an average of
over ten per hour, and in one hour there were thirty-two. In
the last twenty-four hours there were 407, and in the last
twelve hours no fewer than 261. It seems almost incredible
that any constitution could stand such a terrible strain for so
long.
In regard to treatment, drugs seem to have no effect. It
will be noticed that the fits ceased for eight hours after bleeding,
saline infusion, and delivery. After a hot pack they also ceased
for one hour, and again for five hours after a cellular transfusion.
After the intracellular infusion and the second bleeding and
third (intravenous) infusion, they lessened, but did not entirely
cease. The final intracellular infusion seemed to have no
effect. Eleven pints of saline solution was used, seven of them
directly into the vein. In the third infusion I doubled the
quantity of sodium acetate. I did this in the hopes of neut-
ralising any lactic acid which might have formed in the blood.
Lactic acid has been found to be present in the blood of
eclamptics, and it has been suggested that the efficiency of my
solution is due to the neutralising effect of the sodium acetate.
176 EPILEPSY AND THE STATUS EPILEPTICUS,
The patient's blood must have been well diluted, and as the
kidneys and skin were acting so well, one would have expected
that if a toxin were present it would have been flushed out.
The removal of the cerebro-spinal fluid did no good. The
tension did not seem to be raised except during the fits. I
tried the injection of stovaine, but the effect was very alarming,
and for a time I thought the heart would be paralysed. The
injection of hot milk and brandy into the stomach and -fa of a
grain of strychnine hypodermically had a splendid effect upon
the heart, and soon brought the pulse back to the wrists. If I
should ever have another such case to treat, I shall be inclined
to try the effect of an injection of potassium bromide.
[By a curious coincidence at the date on which I read this
paper, I had under my care in hospital two cases of epilepsy,
and I also admitted a third one about ten days later. I shall
give short notes of these three cases.
Case II. — A., jet. 34, ii.-para, was admitted to hospital on
28th April 1907, under the care of Dr Munro Kerr, and she
came under my care on 1st May, when I took up duty.
The patient's first child was born four years ago, and died
in November 1906, with cerebral symptoms following a
discharge from the ear. Previous to her first pregnancy the
patient had never had any convulsions, but when the pregnancy
was three or four months advanced, fits had commenced to occur,
and at that time as many as fifty had occurred in twenty-four
hours. Since this pregnancy she had had attacks of petit mal
every few weeks. These attacks had become less frequent of late.
On 24th April the patient complained of headache, and on
the 25th she had one fit, on the 26th four fits, on the 27th
eight fits, and on the 28th nine fits.
On admission, the patient was conscious between the fits,
and, though dazed, she was able to answer questions intelli-
BY PROF. ROBERT JARDINE. 177
gently. She was seven and a half months pregnant. There
was no indication of labour. There was a very faint trace of
albumen in the urine, but no oedema.
At 5 p.m., 2 J pints of saline solution were infused into the
median basilic vein, and 7 grains of calomel followed by
magnesium sulphate were given and £ gr. of morphia
hypodermically. Four fits occurred before midnight.
29th April. — Hypodermic injections of £ gr. of morphia
were given at 1.30 a.m. and 4.50 a.m., and also 30 gr. chloral
and 60 gr. of potassium bromide per rectum at 3 p.m., but the
fits continued. Strychnine ^ gr. was given four-hourly.
Twenty- three fits occurred during the day. At 8 p.m., Dr
Kerr performed vagina] Cesarean section and emptied the
uterus.
30 th April. — The patient had forty-two fits.
1st May. — The patient had nine fits.
2nd May. — The patient had two fits.
3rd May. — The fits had ceased, but the patient was very
delirious. The restlessness and delirium continued for three
days, and after that recovery was rapid.
It will be noticed that the greatest number of fits occurred
on the day after delivery. There were 102 fits in all. The
case might be termed one of the status epileptic us. The
fits first began during pregnancy, so that according to Turner's
classification pregnancy would be given as the original cause.
Case III. — Mrs M. S., set. 21, iii.-para, was transferred to
the Maternity Hospital from the Eoyal Infirmary, where she
had been under treatment for epilepsy for some weeks.
Her mother was eight years ago confined for some time in
an asylum. There is no other history of mental disease in the
family. The patient's two children are alive and healthy.
The patient states that as a girl she enjoyed good health,
but her parents have told her that she had convulsions when
M
178 EPILEPSY AND THE STATUS EPILEPTICUS,
she was 12 years old. She has no recollection of them. She
was married four years ago, and her first child was born in
June 1904. When six months pregnant she began to take fits,
and as pregnancy advanced they became more frequent, two
or three a week. Just before labour they become much more
frequent. She says she was unconscious during the labour, and
for a couple of hours afterwards. She had about two fits a
week during the puerperium. She could not nurse her baby.
During the second pregnancy she had about three fits per
week. The child was born in December 1905, at full term.
The patient was again unconscious during the labour. As on
the first occasion, a midwife attended.
The third, present, pregnancy began about seven months
ago. Between the second and third pregnancies she had had about
three fits a week. About seven weeks before admission to the
Maternity Hospital the fits became more frequent, and she
fell and injured her face during an attack. She was admitted
to the Koyal Infimary, and after four weeks' treatment in the
Infirmary the fits ceased. She had four fits on the day
of admission. She had never had any treatment for the fits
prior to this. She was transferred to the Maternity Hospital,
as a slight vaginal discharge of blood had commenced.
There was no indication of labour; the urine contained a
trace of albumen ; the bromide mixture of 15 gr. doses thrice
daily was continued.
Two days after admission labour came on, and a premature
female child (3 lbs.) was born alive, but only lived five hours.
There were no fits during the labour, and there was only a
very slight one in the puerperium, on the first day she was
allowed out of bed.
The patient stated that she never had any warning of an
attack, and she was usually unconscious for some hours after a
seizure.
In this case there is the history of convulsions at the age
BY PROF. ROBERT JARDINE. 179
of 12, so that there was a predisposition, but pregnancy was
the exciting cause. In both of these cases there was a trace of
albumen in the urine.
Case IV. — Mrs B., v.-para, set. 26.
The patient's mother committed suicide, after a former
unsuccessful attempt, by eating rat poison. Of her father's
brothers one died in an asylum two years ago, and another
is in an asylum at present.
At the time of her mother's death she was ten months old,
and was being nursed by her mother. Shortly afterwards she
is said to have begun to take convulsions, and she can
remember having had convulsions as a child. After the age of
13, the attacks were not always of a convulsive nature. She
sometimes lost consciousness, but did not struggle. Her
friends informed her that in some of the attacks she acted
and spoke in an unusual way, but she has no recollection of
this.
She was married seven years ago, and since marriage the
attacks have never been convulsive, but have consisted of loss
of consciousness, with strange actions or remarks. She is now
pregnant for the fifth time. One of the previous pregnancies
was a twin pregnancy. One of the twins died at the age of
three and a half months, but all the other children are alive and
in good health, except one which is rickety. Her labours have
been slow but natural. During pregnancy the attacks have always
been much less frequent than at other times. When she was
nursing, the attacks were more frequent — about once a
fortnight.
The labour was natural, and the patient had no attacks
while in hospital.
In this case pregnancy seems to have had a beneficial effect
on the attacks, but it will be noticed that the attacks were most
frequent during lactation. In this case there would be a
180 EPILEPSY AND THE STATUS EPILEPTICUS,
strong hereditary predisposition. So far, the children show no
tendency to neurotic attacks.]
I am indebted to my residents, Drs Melson and Walker,
for the careful notes of these cases, and to Dr Carstairs
Douglas for the post-mortem reports.
Dr Ritchie said they owed a deep debt of gratitude to
Prof. Jardine for having submitted so very interesting a record
of the case. He agreed with Dr Jardine that if one obtained
a history of pre-existing fits, one was justified in diagnosing
epilepsy in that particular case; and that if there was no
previous history of fits, then the case was one of puerperal
eclampsia. He had had a good many cases of puerperal
eclampsia, but in none of the cases was there afterwards a
development of epilepsy. As to treatment, if one diagnosed
epilepsy, the treatment was that for epilepsy ; one would not
expect in such a case to find benefit from the treatment which
is necessary for puerperal eclampsia.
Dr Haultain said he could only follow suit to what Dr
Eitchie had said. The question of epilepsy was a subject of
very great interest to him, as he had had a considerable
experience in the subject both in the Maternity Hospital and
in consulting practice. He was only sorry the subject had
been sprung on them, as it were, when otherwise he might have
been able to have gone over some notes of cases he had seen.
On a haphazard recollection he would divide epilepsy in preg-
nancy into two great groups — (1) where previously there had been
epilepsy, and (2) where there had not previously been epilepsy.
In the first group his experience seemed to show that the effect
of pregnancy was most irregular. In several cases pregnancy
had absolutely no effect at all upon the disease. In another
BY PROF. ROBERT JARDINE. 181
set of cases the condition was exaggerated. In two cases
before his mind, one was in a condition of status epilepticus.
She was from five to six months pregnant. He decided to
procure abortion, and did so, but in spite of his efforts the
patient died. In the second case the patient was having an
exacerbation of fits, and from previous experience he thought
the pregnancy should be ended. Abortion was procured ; the
patient survived, but lapsed into the old condition — having fits
occasionally, but in no way exaggerated. There was a third
set of cases where undoubtedly epileptic fits seemed to be dimin-
ished. He had read of, and thought he had seen cases where
the presence of pregnancy seemed to alleviate the tendency
instead of exaggerating it. As to cases where epilepsy first
commenced during pregnancy, others of course brought out
the question of the differential diagnosis between epilepsy and
eclampsia. There was no doubt that he was in accord with
what Dr Jardine had said regarding the question of epilepsy
in pregnancy and labour. He did not believe these were cases
of eclampsia at all unless there was albuminuria. He had
never seen true eclampsia where there was not highly
albuminous urine, much diminished in quantity. He had
certainly seen one case where epileptic convulsions developed
during pregnancy and returned during a subsequent pregnancy,
and in the interval there were no fits at all. Again, in another
case where the patient had undoubtedly puerperal eclampsia,
highly albuminous urine diminished in amount after the
confinement was over ; in eight to ten days she again took fits
at a time when there was no albumen in the urine. This case
temporarily upset his ideas on the subject of puerperal eclampsia
and albuminuria, and he thought the case was one of epilepsy ;
and so it turned out to be, as the patient had taken fits several
times since, independently of pregnancy. The origin had been
with puerperal eclampsia, and had remained as epilepsy after-
wards, showing (he difficult problems there were to be considered.
182 EPILEPSY AND THE STATUS EPILEPTICUS,
One would expect the condition of epilepsy to be aggravated by-
pregnancy — a time when there is a toxaemic condition ; yet, in
spite of this, epilepsy in some cases is not so virulent as
before, and it therefore seems that we have nothing to prove
either in one thing or another as to the effect of pregnancy
upon epilepsy. As to treatment and the question of marriage.
People who had epilepsy should never marry under any cir-
cumstances, on account of the hereditary transmission of the
disease. If fits should become aggravated, the uterus should be
emptied to prevent any condition of status epilepticus occurring,
or even the undermining of the mental condition from frequent
convulsions, As to the treatment by strychnine, it seemed a
somewhat radical measure.
Professor Jardine here explained that strychnine was given
to keep the patient alive.
Dr Haig Ferguson had very little to add but to convey his
thanks to Professor Jardine for his interesting paper. Both Dr
Jardine and Dr Haultain had stated that they had never seen
cases of eclampsia where there was no albumen in the urine.
He had strong and good grounds for believing that eclampsia
could exist without any albuminuria. What was more im-
portant was the question of the diminution in urea. He had
seen cases of typical eclampsia where to begin with there had
been no albuminuria, but where the amount of urea was con-
siderably diminished. He had always been of the belief that
puerperal convulsions should not be regarded as epileptic if
the patient had no previous history of epilepsy, though a patient
with a previous history of epilepsy might take puerperal con-
vulsions. One case occurred to his mind, where the woman in
her first pregnancy took a large number of convulsions which
were supposed to be eclamptic. There was no diminution in
the urea and no albuminuria. On making a close inquiry into
the previous history, it was discovered that the woman had had
attacks of petit mat at every menstrual period. In this case
BY PROF. ROBERT JARDINE. 183
the condition of epilepsy had been aggravated during pregnancy.
He had never seen a case where the fits were cured by preg-
nancy. All the cases he had seen had appeared to have had the
condition somewhat aggravated by the pregnant condition. He
would say that any woman who had epileptic convulsions
during pregnancy had had epilepsy on some previous occasion.
They were greatly indebted to Dr Jardine for his paper.
Dr Porter had had one case, eight months ago, a primipara,
19 years of age, who had had regular epileptic seizures,
aggravated at every menstrual period. At the seventh month of
pregnancy she had developed slight albuminuria. The labour
was quite normal. She had two fits about the fifteenth day of
the puerperium, which were easily controlled by bromide.
The child had been delivered naturally.
The President said his experience was along the lines of
these mentioned. He remembered one case at the Dispensary
where the patient had epilepsy except during the times of
pregnancy, the epilepsy returning again a month after the
pregnancy was over. He afterwards came across one or two
other cases where this did not apply, and he had had quite a
number of interesting cases at the Maternity Hospital. The
main result of them had just been that some were better during
pregnancy, and some were worse. Some were free during
pregnancy, and some were free except at the time of pregnancy.
There were not many where there was any special development
during pregnancy. With regard to the relationship of eclampsia
and epilepsy, they must come to the conclusion that the
eclampsia we had in this country differed in some way from
that in America and other parts of the world. Americans
constantly assured him that they had a number of cases where
there was no albumen in the urine, and said that a great
number of their cases were nervous, and to be included under
epilepsy and hystero-epilepsy rather than eclampsia.
Prof. Jardine, in reply, said there was a fair amount of albumi-
184 BILATERAL OVARIAN DERMOID TUMOURS,
nuria in all cases of eclampsia, and also diminution of urea.
He wished some of those accustomed to deal with such cases
in asylums had been present at the discussion. It was an
extremely difficult thing to decide about the . question of
epilepsy in connection with pregnancy. They knew that the
effect of pregnancy on the nervous system of women varied
very much, and they could imagine that the same differences
would show themselves in those who were the subject of
epilepsy. He had only had one or two cases of epilepsy where
the patient had seemed to be better during pregnancy. Last
year he had reported a case of recovery after two hundred fits.
He had looked on that case as eclampsia, but it might have
been epilepsy, although she had never had a fit before.
VI. BILATERAL OVARIAN DERMOID TUMOURS,
COMPLICATING PREGNANCY.
By Dr Malcolm Campbell.
While the keen attention which has recently been directed to
the identification of endotheliomata has undoubtedly upset the
recognised order of relative frequency among ovarian tumours,
yet dermoids must always, from their nature, continue to
maintain their position as the most interesting form of tumour
with which the gynaecologist comes in contact. Though
dermoids can no longer be regarded as rare tumours, yet they
undoubtedly are still relatively rare. In the seven volumes of
Transactions which this Society has issued during the present
century, there are records of only fifteen dermoids having been
exhibited. A liberal computation of the frequency of dermoids
puts them down as from 3 to 4 per cent, of all ovarian tumours.
Of all forms of ovarian tumour, the dermoid is the one
most frequently associated with pregnancy. M'Kerron has
tabulated 113 cases in which ovarian tumours complicated
BY DR MALCOLM CAMPBELL. 185
pregnancy — of this series no fewer than forty-six were dermoids.
Besides being the type of ovarian tumour which most frequently
complicates pregnancy, the dermoid is the most dangerous, for
in this series of forty-six cases there were eighteen maternal
deaths due to injury of the tumour during labour.
While dermoids, both as ovarian tumours and in their
relationship to pregnancy and parturition, offer an interesting
field of study, the subject of bilateral ovarian dermoids is even
more interesting. In regard to the frequency of the condition,
the experience of gynaecologists varies within wide limits.
Howard Kelly, in a series of eighty-seven cases in which he
operated for ovarian dermoids, only found the condition bi-
lateral in one instance. Munde, in a series of fifteen operations
for dermoids, found the condition bilateral in three cases.
G-ebhard, out of 107 cases, found bilateral dermoids no fewer
than sixteen times.
In 1902, Loewy and Paul Gueniot published a paper on
the subjeet of bilateral dermoids, in which they were able to
collect ninety-eight cases. In thirty of these cases the patient's
reproductive history was given. In five patients there was a
history of one pregnancy, while five others had each given
birth to two children. The other cases had all had more than
three children, and in one case there was a history of seven
full-time pregnancies and five abortions ; while another patient,
prior to operation, had borne twelve living children, and in
addition had one abortion.
I have been able to find references to only nine cases in
which bilateral ovarian dermoids were removed during preg-
nancy ; and I have also found the notes of a case, published by
F. Page, who operated on a patient for peritonitis, two and a
half months after labour, — when the abdomen was opened,
bilateral ovarian dermoids were found.
Of the nine double ovariotomies for dermoids during
pregnancy, I have only been able to see the original communi-
186 BILATERAL OVARIAN DERMOID TUMOURS,
cation in one case, viz., that of Knowsley Thornton, in which,
on 4th February 1886, he removed bilateral dermoids from a
patient who was delivered of a full-term foetus on 23rd June of
the same year.
Though the preceding notes can in no sense be regarded
as a review of the literature of the subject, the figures I have
quoted seem to me to amply justify my bringing the following
case to the notice of the Society : —
The patient, Mrs F., set. 32, was admitted to Dr Brewis's
ward on 2nd June 1906. She had been married twelve years,
and had five children, the eldest set. 10, the youngest aet. 2
years and 3 months. Beyond some premenstrual dysmenorrhea
before marriage, there was nothing to note in regard to
menstruation, which began at 14, was of twenty-eight-day
type, and lasted four days. There had been amenorrhoea from
March 1906.
Before the onset of her present illness, six months prior to
admission, patient had enjoyed perfect health.
On admission, the patient complained of pain in the right
side, which she stated went round to her back. The onset of
the pain in January 1906 was sudden, and the pain so severe
that patient had to remain in bed for a week, and was only
able to lie on her left side. During this attack there was
some vomiting. There was no vaginal discharge. Since the
initial attack there had been several returns of the pain at
intervals. The pain came on without any discoverable cause,
lasted for about an hour, and then passed off. The pain was
worst in the right iliac fossa, then from there it radiated to the
back. She occasionally had vomited with these attacks.
About three months before admission, patient first noticed a
swelling on the right side of the abdomen. The last attack of
pain occurred about a week before admission.
Physical Examination. — The abdomen was seen to be
BY Dll MALCOLM CAMPBELL. 187
slightly distended by a swelling passing from the right lumbar
region to midway between the sternum and the umbilicus.
This swelling moved freely with the respiratory movements.
On palpation, a tumour was found extending from the mid-line
to the anterior axillary line on the right side. The tumour,
which was flattened antero-posteriorly, seemed to be disc-shaped,
and was about 4 inches in diameter. The tumour was not
sensitive on palpation. It was not uniform in consistence, and
could be moved freely. If pulled upon, a tense band could be
felt running down into the pelvis. The uterus could be felt in
the hypogastric region. There was no free fluid, in the abdomen.
On vaginal examination the uterus was found enlarged, and
undergoing rhythmic changes in consistence. There was marked
pulsation in both lateral fornices. In the left lateral fornix,
posteriorly, a hard irregular non-sensitive body about the size
of a hen's egg could be felt ; this was evidently the displaced
left ovary. The right ovary could not be felt.
On 6 th June the abdomen was opened, and the tumour
above described was found to be an ovarian tumour with a very
long pedicle, growing from the right side : it was removed in
the usual way. On removal it was about the size of a foetal
skull, and on being incised was seen to be a dermoid tumour
containing sebaceous matter, hair, and teeth.
The left ovary was examined; an attempt was made to
resect this ovary, in order to conserve for the patient some
ovarian tissue ; as this, however, was found impracticable, the
whole ovary was removed. On examination, it was found
also to be a dermoid cyst containing sebaceous material and
hair.
The patient made a most satisfactory recovery. Before
leaving hospital, a month after the operation, patient felt foetal
movements, but on auscultation no festal heart sounds could be
heard.
Since leaving hospital on 7th July, patient has beon
188 BILATERAL OVARIAN DERMOID TUMOURS,
perfectly well She was delivered of a living child on 9th
December.
The fact that both ovaries were removed at the end of the
third month of gestation adds another point of interest to the
case, for Heil has shown that abortion is most likely to occur
in the cases in which the corpus luteum is removed before the
fourth month.
In regard to the endeavour to conserve a portion of ovarian
tissue, it is interesting to note that Matthei, Schroeder, and
Terrier have all recorded cases in which pregnancy followed
the removal of bilateral ovarian dermoids, where it had been
found possible to conserve some ovarian tissue.
In conclusion, I should like to express my thanks to Dr
Brewis for permission to communicate this case, and to Dr
McMaster for some notes on the case.
Dr Haultain was much interested in the case Dr Campbell
reported. Personally, he had not had any experience of remov-
ing bilateral dermoids, though on several occasions he had
removed a dermoid from one side. In this connection there
was an interesting case of a person he saw four or five years
ago, in whom he had diagnosed ovaritis. The patient suffered
a very great deal of pain, and said life was not worth living.
He had no room for her in his home at that time, but sent
for her to come in three weeks later, and without examining
again, proceeded to operate. He thought at the time of opera-
tion that the uterus was a little large and purplish in colour,
but removed the ovaries. The patient was delivered at full
time of a healthy child. This case showed that even at that
early date removal of the ovaries seemed to have no effect on
the growth of the foetus. At the present time there were a
large number of researches on the corpus luteum of pregnancy.
So far, they seemed to show the corpus luteum had very little to
BY DR MALCOLM CAMPBELL. 189
do with pregnancy. He thanked Dr Malcolm Campbell for
having brought forward the case.
The President had not met with a case of double dermoid,
but had had four or five cases of single. As to ovarian secre-
tion, the theory which had always seemed to him to be an
extraordinary one, was that the corpus luteum was the secretory
gland of the ovary travelling about from different parts of the
ovary in different months, simply being functional in one part
for one month, and then in another. If one looked at it from
the point of view of luteum, what was luteum? It was a
perfectly innocuous thing, and going on that line he had
always been sceptical about theories brought forward as to the
curative value of lutein and the corpus luteum.
Dr Malcolm Campbell, in reply, said he had kept purposely
off the corpus luteum. But although, as some maintained, the
corpus luteum might do nothing, it should be treated with
some respect, and left where possible.
Meeting VII. — June 12, 1907.
• Dr J. W. Ballantyne, President, in the Chair.
I. Dr Brewis exhibited — (a) A full-sized crochet-needle,
removed from the right iliac region of a patient who had
pushed a needle into the vagina and lost it. Five weeks later,
on admission, a hard parametric mass was felt anterior to the
supravaginal part of the cervix ; and to the right, about an inch
above the middle of Poupart's ligament, there was a projecting
mass which was suspected to contain one end of the lost
needle. On cutting down on the mass, this was found to be
the case, and the needle was extracted.
(6) A large slough from the interior of the uterus,
190 EXHIBITION OF SPECIMENS.
produced by the use of chloride of zinc in a case of inoperable
carcinoma. On microscopic examination, the specimen was found
to consist of vascular fibrous tissue and unstriped muscle.
These were both necrotic in parts and infiltrated with leucocytes,
while there was also some infiltration of epithelial cells, suggest-
ing the presence of carcinoma. The slough was fully an inch in
diameter, showing that destruction of the uterine wall by the
zinc had been extensive.
(c) A cystic swelling, somewhat pear-shaped, with a long
axis of 8 J inches, and a circumference of 11 inches at the
broad end of the pear. It was a monocyst, formed by the
junction of cystic right and left Fallopian tubes, and a dis-
tended and unrecognisable right ovary. The contents were
caseous-like, and consisted of fatty matter and cholesterin
crystals, while on certain parts of the walls, internally, were
deposits of calcareous matter.
(d) Uterus, containing a large submucous fibroid,
attached by a broad pedicle to the fundus. The uterus was
removed by supravaginal hysterectomy along with both ovaries,
one of which was converted into a monocyst the size of a
tennis ball, while the other contained a haematoma.
(e) Large soft edematous fibroid tumour, removed by
hysterectomy. The tumour presented physical signs closely
resembling a six months' pregnant uterus.
(/) Uterus removed by vaginal hysterectomy for bleeding,
and, from the same patient, a hematoma of the left broad
ligament.
II. Br Haig Ferguson showed — (a) extra-uterine preg-
nancy, nearly four months' duration. The tube had ruptured
in the country. When seen in town, there was a swelling
behind the uterus, and extending well up into the abdomen,
and one waited to see if it was growing, and as it was found
to be rapidly growing, it was removed by abdominal section.
The tube had ruptured into the cavity of the broad ligament.
EXHIBITION OF SPECIMENS, ETC. 191
(b) Specimen from patient, a multipara, aet. 44, suffering
from irregular haemorrhages. The uterus was scraped 7th June,
and the pathologist's report was as follows : — " Gland tubes of
highly irregular shape, lined with columnar cells, irregular in
arrangement, forming numerous papillae within the lamina of
the tubes. The epithelial formation is disproportionately great
in comparison with the connective tissue. A specimen of the
early stage of a rapidly developing papillary adeno-carcinoma
of the body of the uterus." The uterus was removed by vaginal
hysterectomy. This was the fifth case of malignant fundus he
had operated upon in the last year by vaginal hysterectomy,
with satisfactory results.
III. The President showed a photograph of a native mid-
wife of Nazareth, with a trained midwife from this country
standing beside her.
IV. SIX CASES OF VAGINAL CESAREAN SECTION.
By N. T. Brewis, M.B., F.R.C.S.E., Gynaecologist, Royal Infirmary,
Edinburgh.
When I listened to Dr Munro Kerr's paper delivered before
the Society some three years ago, in which he described in a
very lucid manner the operation of vaginal Caesarean section,
introduced by Diihrssen, it brought to my mind more than one
case where, had I been conversant with the procedure, I would
have been glad to take advantage of it. One case particularly
I recalled of a patient in the country, four months pregnant,
brought to the point of death by severe and uncontrollable
vomiting, whose cervix was so rigid that Bossi's dilator was
unable to effect dilatation of the internal os to any extent, and
the foetus and placenta had to be extracted bit by bit through
an opening no bigger than a keyhole. When I considered that
the time, energy, and force spent in the attempt to overcome
the resistance could have been saved by a few cuts with the
192 SIX CASES OF VAGINAL CESAREAN SECTION,
scissors, the value of Diihrssen's operation came home to me
and made me determine to practise the method on the first
suitable occasion.
The opportunity soon occurred. The following notes of my
first case were kindly furnished me by the patient's medical
attendant, Dr Henderson, Kirkcaldy : —
Case I. — Vomiting of Pregnancy. — "Mrs H., aet. 30.
Previous and family history good. In January 1903, when two
months pregnant and in her first pregnancy, she began to
suffer from severe and intractable vomiting. The usual
medicinal remedies were of no avail. Eectal feeding had to be
adopted. Operative interference was seriously considered,
when she spontaneously aborted. She made a rapid recovery.
" On 29th November 1905, when three months pregnant
and in her second pregnancy, she was again prostrated by
severe vomiting. As before, medicinal remedies were found of
no avail. All nourishment given by the mouth was returned.
The vomiting and retching was persistent, and independent of
the taking of food or medicine. On 6th December 1905, Mr
Brewis dilated the cervix under chloroform. The vomiting
gradually subsided, till in ten days' time the patient was able
to retain and enjoy food, and was up and about.
" On 1st February 1906, vomiting again set in, producing very
rapidly great prostration, emaciation, and dusky complexion.
The patient presented the appearance of one overwhelmed
with a profound toxaemia. On 3rd February her condition was
desperate. On that day Mr Brewis performed vaginal Cesarean
section. She had slight vomiting for two or three anxious days,
and then absolute recovery."
I operated twice on this patient — first in November, for
severe vomiting, when the patient was three months pregnant.
Though the vomiting was severe the patient was not seriously
ill, and I performed the operation which I had found most
BY DR N. T. BREWIS. 193
useful in those cases, viz., dilatation of the cervix, followed by
the administration of chloral per rectum.
At my second visit, three months later, the patient's life
was in danger so imminent that I considered it indicated to
empty the uterus as quickly as possible.
A month later I had another opportunity of putting the
operation to the test in a case equally serious, but belonging to
quite a different category.
Case II. — Eclampsia. Delivery by vaginal Cesarean section,
at seven and a half months, of a living child, followed by complete
recovery of mother. — Mrs B., set. 26, was married in November
1905, and came under my care on 20th March 1906, when she
was six months pregnant. The following is the history of the
case : — A week before admission she first noticed her feet
swollen. The swelling was slight, and not painful. A few days
later her face and hands also swelled, and she felt pain low
down across her back. About three weeks ago she had a bad
cold and cough. This condition lasted a week, and was almost
like whooping-cough, and prevented sleep. A week before
admission she got cold again, and had a slight cough on
admission. Her last period began on 5th November, and lasted
three days.
She had suffered from headaches, chiefly occipital in
character.
She had scarlet fever when about six years old. There was
no history of kidney trouble.
On admission, the face was puffy, especially the eyelids.
There was slight oedema of both hands. Both feet and legs
were oedematous, the right ankle more so than the left.
She suffered from breathlessness on exertion. The pulse
was regular and of high tension.
The thyroid gland was enlarged. The breathing was harsh,
but there were no accompaniments.
N
194 SIX CASES OF VAGINAL CESAREAN SECTION,
Albumen was present in the urine in large quantity.
Two days before operation patient had a fit, followed by a
semi-conscious condition. On the next day she had two fits.
On the morning of the day of operation she had a fit, after
which she remained in a semi-unconscious condition all day.
No urine was passed that day. The operation was performed
in the evening.
The operation is as follows : —
The patient was put in the lithotomy position, and after the
customary preparation for major pelvic operations the vaginal
portion of the cervix was drawn down to the vulva.
The anterior vaginal wall was divided transversely im-
mediately above the external os, and along with the bladder
was pushed upwards. The anterior surface of the cervix was
cleared in this manner, and then divided vertically in the
middle line with scissors for 3 or 4 inches. The membranes
were then ruptured, and forceps applied to the child's head,
which was lying in the most common position. Gentle traction
was used, and after a quarter of an hour's manipulation the child
was delivered. The placenta was expressed a short time later.
The cervical incision was sewn together with catgut. Then
the anterior wall of the vagina and the bladder were stitched
into position. The uterus was irrigated with weak lysol
solution, and the patient put to bed.
Although the traction required was considerable, there was
no tearing of the wound farther up. Probably the cervical
wound might have been made 1 inch longer without injury.
The patient, after a tardy recovery, complicated by a severe
attack of broncho-pneumonia, returned home on 11th May.
She is now in good health. The child, although premature, was
by the aid of an incubator kept alive, and though it had a
considerable struggle for existence, was sent home when about
a month old. It is now a strong and healthy child.
With regard to the applicability of this operation to cases
BY DR N. T. BREWIS. 195
of eclampsia, I would say that if it is conceded that in grave
cases the uterus should be emptied rapidly, Diihrssen's opera-
tion, owing to the safe, simple, and rapid manner in which it
can be performed, is a most rational and proper procedure, and
one which is much to be preferred to the classical Cesarean
section. In less urgent cases the slower methods of dilatation
may still have a place, though, if good results are to be got,
I think the principle of not waiting too long should be adopted.
Statistics show better results by this method than by any
other. Veit performed the operation thirty-three times for
eclampsia with only one death, and Diihrssen has collected 112
cases having a mortality of 15 per cent.
Case III. — Stenosis following Amputation of the Cervix. —
The patient, Mrs B., was operated on by me in March 1905, for
a large retroverted uterus and hypertrophied eroded cervix.
The vaginal portion of the cervix was amputated. The uterus
was curetted and replaced, and the round ligaments shortened.
I next saw the patient in May of the following year, and she
was then five months pregnant. She went into labour at end of
September 1906, and when I saw her some waters had escaped,
the head was presenting ; no external os could be felt, but the
lower uterine segment was thinned and spread over the pre-
senting part. The patient had suffered from pains at intervals,
and was apparently in labour. Eupture of the extremely thin
uterine segment was feared. The patient was prepared for
operation.
A transverse incision was made through the vaginal wall in
front of the presenting part. The bladder was pushed up, and
the lower uterine segment divided vertically as high as the
internal os. The foetus was delivered with forceps, and the
placenta expressed. The patient made a good recovery.
Case IV. — Heart Disease — Mitral Stenosis and Incompetence,
196 SIX CASES OF VAGINAL CESAREAN SECTION,
with (Edema of Lungs. — Operation performed at five and a half
months. The following are the notes which were kindly given
me by her medical attendant, Dr Fleming : —
" I first attended Mrs D. in June 1906, for cough due to
slight oedema of the lungs. Her heart was dilated. The
impulse was felt fully 1 inch outside the nipple line, accom-
panied by a thrill due to mitral obstruction and incompetence.
At intervals, chiefly at night, she had attacks of dyspnoea and
heart pain. She was able to walk a short distance.
" She told me on the 18th November that she had not men-
struated since the middle of August, and that but for slight
squeamishness she felt nothing wrong. In fact, she had not
felt so well for a long time. I had been called to see her at
the time because of slight bleeding, probably induced by being
shaken in a motor bus. This was relieved by a few days' rest
in bed. During the early weeks of December she had attacks
of dyspnoea and cardiac pain, and was put on inf. digitalis —
which she had been taking at intervals since 1904 — and tabell.
trinitrini. Under this treatment the cardiac pain diminished,
the pulse got stronger and more regular, and she was able to
walk better. About the 24th of December she went on a visit
of three weeks duration to Glasgow, and while there had a bad
attack of dyspnoea and cardiac pain. The induction of pre-
mature labour was considered at this time, but it was finally
decided to allow the pregnancy to go on.
"On 17th January 1907, her heart was very irregular in
action. She had not had sleep for some weeks on account of
the dyspnoea and cardiac pain. There was oedema of the lungs.
On the 19th January Dr Brewis came to see her, took a very
grave view of the case, and advised operation."
On admission, the uterus was found to be enlarged to the
size of a six months' pregnancy. The cervix was firm to the
touch.
The vulvar aperture was enlarged by making an 'incision
BY DK N. T. BREWIS. 197
about f of an inch long into the anterior part of the perineum.
The cervix was pulled down, an incision was then made through
the vaginal wall at the junction of the vagina with the cervix
in front. The anterior aspect of the cervix was exposed by
pushing up the bladder. The cervix was then cut open by
scissors through the whole length of the anterior part until
the uterine cavity was opened into. An incision about \ an
inch long was made in front into the lower part of the body of
the uterus. The membranes were exposed. These were ruptured,
and the liquor amnii allowed to escape. The breech was found
to be presenting. The lower limbs and trunk were delivered,
and difficulty was experienced with the after-coming head.
Forceps were applied, and the head delivered. The child was
dead. It was a well-developed five and a half months' foetus.
The placenta was then separated and expressed. The incision
into the anterior and lower part of the body of the uterus and
the incision into the cervix were closed with interrupted stitches
of strong catgut. The uterine cavity was washed out with a
warm saline douche. The incision in the anterior fornix was
closed with sutures of medium catgut, and the perineum was
repaired with a sub-cuticular stitch of medium catgut. A small
gauze drain was put into the cervical canal. Gauze was also
packed into the vagina after it had been douched with hot
saline.
She was somewhat breathless for two days after the opera-
tion. On the third day she was able to lie in the recumbent
position. She went home on the 16th February feeling very
well. She had no distressing breathless attack after the
operation. On her dismissal she was still cyanosed, especially
marked on her cheeks, ears, nose, and finger nails, and there
were fresh small sub-conjunctional haemorrhages.
It was evident from the extreme distress which this
patient's cardiac condition occasioned, that the termination of
her pregnancy was urgently indicated, and the only question to
198 SIX CASES OF VAGINAL CESAREAN SECTION,
be considered was the method to be adopted. Her cardiac
condition appeared critical, and it seemed evident that the
more speedily the uterus could be emptied, the less would be
the strain on the heart, therefore it was decided to perform
vaginal Csesarean section. The result was very satisfactory.
Case V. — Haemorrhage due to Premature Separation of 'part
of a Low-Placed Placenta — Placenta Prwoia. — Mrs T., ret. 38,
had been married sixteen years, and had six children, the last
being born eighteen months before admission. She had a
miscarriage at two and a half months, three years before
admission. She was admitted on 7th June 1906, complaining
of floodings.
At the beginning of March, while still nursing her child,
the milk ceased, and patient had a severe bleeding for a day
and a night. She got up next day and felt quite well till five
weeks later, when she had a second flooding. The bleeding
came and went for a day or two, and she was confined to bed
for a week. On getting up she felt weak and went for a
holiday for a week, and on returning home she again had red
discharge. The discharge came on every night for two weeks
— not copious, only coming away when she lay down. At the
end of two weeks another flooding took place, and for the four
weeks previous to admission she had been confined to bed with
a more or less constant red discharge.
Before the present illness her menstrual history had shown
nothing of a morbid nature. Her labours were natural, and
she had no serious illness.
On admission, a tumour was felt in the abdomen, suggesting
a six and a half months' pregnancy. At parts the swelling
was soft and doughy, and at others hard. There was greater
resistance on the right side as a whole, and on this side harder,
irregular masses were felt, suggestive of limbs. Foetal heart
sounds were audible just below the umbilicus in the middle
BY DR N. T. BREWIS. 199
line. Per vaginam, a sense of doughiness of the lower uterine
segment was felt. For a week she continued to pass clots, and
on the eighth day after admission she had a profuse haemorrhage,
accompanied by severe abdominal pains, having the character
of labour pains. The patient was very weak and exhausted.
In the evening of that day it was decided to deliver as rapidly
as possible. It was found that the external os had dilated
very slightly — only sufficiently to allow the tip of a finger to be
introduced. Chloroform was given.
The median basilic vein was exposed, and about a quart of
saline given intravenously. The vagina was then well douched
out, the cervix grasped by strong volsellae, and pulled down.
An incision was made through the anterior vaginal wall
transversely, and the bladder pushed up. A sound being
passed into the bladder, an incision was made along the anterior
surface of the cervix and continued beyond the internal os.
The presenting part was seen as a bluish sac. The membranes
were ruptured, and the liquor amnii allowed to escape.
On introducing the fingers the placenta was felt to one
side, low down, and the head of the child was presenting. The
child was delivered by forceps. The hand was then introduced
to remove the placenta, which was partially adherent. After
expressing the placenta the interior of the uterus was douched
with hot sterile water. The incisions in the uterus and vagina
were closed by catgut sutures. She made a good recovery.
This case was one of premature detachment of a portion of
a low-placed placenta. Possibly at an earlier stage rupture of
the membranes or slow dilatation followed by delivery might
have been successful, but at the time that I operated the
patient was in a highly critical state, and I felt that it was
best for the patient to deliver as speedily as possible. I con-
sidered her condition so dangerous that I transfused before the
operation, a plan which I always practise in patients exhausted
from loss of blood.
200 SIX CASES OF VAGINAL CESAREAN SECTION,
The indications for vaginal section submitted by Diihrssen
eleven years ago, were for conditions dangerous to the life of
the mother or child, or both; abnormalities of the cervix and
lower uterine segment, which make impossible or difficult a
dilatation of the cervix by the uterine contractions ; and for
dangerous conditions of the mother which may be removed
by prompt emptying of the uterus, e.g., affections of the
kidneys, heart, lungs.
Whenever the element of time is important, vaginal
Cesarean section is a great addition to our resources. An
operation which enables the hand to pass with safety into the
interior of the pregnant uterus in a couple of minutes' time is
one which might have its indications extended to cases of a less
serious nature, where the mother's life is not in peril, but
where the operation can accomplish the desired end more easily
and more conveniently than any other. Anyone who has had
experience of this operation cannot do otherwise than commend
it. An aseptic field, a clean-cut wound, an easy and rapid
technique, the parts restored at the end of the operation to
their original condition by a few catgut stitches, go to make
an operation which must appeal strongly to anyone witli
surgical instincts.
The last case in which I followed Diihrssen's method was
one in which the patient's life was not in danger. Her uterus
might have been safely emptied by other means, but I pre-
ferred vaginal Cesarean section, because it was as safe as any
other, and was more easily performed.
Case VI. — The patient was two and a half months
pregnant, and haemorrhage had gone on continuously for five
weeks.
All the mothers recovered.
A living seven and a half months' child was delivered in
BY DR N. T. BREWIS. 201
the eclamptic case, and a full-time child in the case of stenosis
of the cervix.
Br Lamond Laekie said he had no personal experience of
the operation, but that during the last quarter at the Maternity
Hospital he had had a case in which he had thought of doing
vaginal Cesarean section. The case was one of eclampsia, the
patient was comatose, and the prognosis was very bad. He
had attempted to dilate the os with Hegar's bougies, and with
Bossi's dilator, but had failed absolutely. The cervix was so
rigid that he felt it would be wrong to persist in the attempt,
and he desisted, with the view of performing vaginal Csesarean
section later. Fortunately the patient began to improve, and
by the following day no further interference was necessary. In
three days there was practically no sign of eclampsia, the fits
had ceased, the albumen disappeared, and five days after the
attempted dilatation 'of the cervix, the patient aborted; the
fact being that during the eclampsia the foetus died. Dr
Brewis's paper was most interesting. There seemed to be so
many possible conditions for which the operation might be
done. He had noticed that Dr Brewis held that the operation
was even indicated where the os might possibly be dilated,
and the foetus delivered in that way. He supposed the opera-
tion was more speedy than dilation of the os, when from
twenty to thirty minutes were required, so that there was a
distinct gain in that way.
Br Haig Ferguson thanked Dr Brewis for his paper. He
had had only one experience of vaginal Caesarean section, but
had found the operation extremely satisfactory — so much so,
that if again in similar conditions, he would prefer it to Bossi's
dilator, which he considered to be extremely dangerous, and
very seldom satisfactory. The patient was a primpara with
202 SIX CASES OF VAGINAL CESAREAN SECTION,
eclampsia. She was about seven and a half months, had had
twelve seizures, and was comatose ; the cervix was very rigid,
no sign of dilatation, and the foetus alive. He determined to
do vaginal Caesarean section, and followed the ordinary routine
as performed by Diihrssen, and got the uterus dilated in a
few minutes, and delivered the child (which presented by the
breech) without any difficulty at all. He sewed up the lower
segment and restored the parts to their former condition.
Unfortunately the patient did not survive. She recovered
consciousness, but again had a succession of eclamptic fits,
and in spite of all treatment died the following evening. But
he was so impressed with the ease with which the operation
could be done, that in a case of eclampsia he should certainly
prefer the operation to the use of Bossi's dilator. The only
thing he should wish to criticise was in doing it in a woman
who was only two and a half months pregnant. The simplicity
of Diihrssen's operation was when the woman was near full
time, and the lower uterine segment more fully developed.
He could not see the reason why, in inducing an abortion one
should have recourse to vaginal Caesarean section, for, un-
doubtedly, there were certain risks; the incision might go so
far up as to open the peritoneal cavity. He should prefer to
induce abortion by dilators rather than risk the opening of the
peritoneal cavity. The only other point was in regard to the
indication in heart cases. He thought the best treatment
was medicinal, and to avoid bringing on labour. He had found
general treatment have, as a rule, satisfactory results. Cer-
tainly in cases of eclampsia, and possibly in placenta praevia,
where one knew the lower uterine segment and the cervix were
extremely friable, a clean cut such as Diihrssen recommended
— one that appealed to one's surgical principles, and one that
would terminate pregnancy in a much more rapid and safe
manner without setting up laceration, was much better. They
were much indebted to Dr Brewis for having stepped into the
BY DR N. T. BREWIS. 203
breach and given them such an interesting paper. He thought
that in the operation one needed to have plenty of skilled
assistants, as it would be extremely difficult to do it if inade-
quately assisted.
The President agreed with the Fellows who had spoken, in
thinking the subject a very interesting one. He was very
glad Dr Brewis had come forward again with an obstetric
paper, or one that was perhaps just on the border-line between
obstetrics and gynaecology, for vaginal sections were more
especially gynaecological. The indications for the operation
had struck him as being extremely interesting from their variety
— vomiting, eclampsia, stenosis of os, heart disease, placenta
praevia. It seemed to him that one might generalise a little
more, and say that cases in which the os was not taken up were
specially suitable ones. In eclampsia, where the os was taken
up the case might be amenable to other measures, but
where it was not taken up there was great risk in using Bossi's
dilator, which gave the risk of severe laceration. Formerly,
the only operation consisted in numerous incisions into
the cervix, which had seemed to him to tempt danger and
possible disaster. But this localised clean cut did seem
to meet the indication where the os was not taken up,
and thus in cases which were not far on in pregnancy.
He thought the reason why the operation was chosen in
the heart case was that there was a condition of a systole,
and that the case was not like many cases in which it would
not matter if one waited for a while. In such a case as that
cited, he considered one would be quite justified in doing the
operation. He supposed that a knife, scissors, and catgut
sutures were about all that was needed for the operation. He
was sure he expressed the feelings of the Society in thanking
Dr Brewis for coming forward at such short notice, and for
giving them such an interesting paper.
Dr Brewis thanked the President and Fellows for the very
204 CONGENITAL GOITKE FOLLOWING ADMINISTRATION OF
kind way in which they had received his paper, though it was
somewhat obstetrical. He considered the cases related in the
paper belonged to the gynaecology of obstetrics. He could not
agree with those who thought the operation only suitable for
hospital. The first case narrated was performed in a private
house, without any special preparation, and with a few
borrowed instruments. A pair of scissors, two volsellse or
forceps, a small curved needle, and catgut are all the instru-
ments that are specially needed. No doubt this, like all other
operations, is best performed in hospital, but when the patient
is not fit to be removed, there is no reason why she should not
have the benefit of the operation in her own house. With
regard to the opinion offered by Dr Haig Ferguson on the
justifiableness of operation in the case of heart disease, Dr
Brewis thought that if Dr Ferguson had seen the case he
would not have* hesitated to recommend the operation. Dr
Brewis considered that the operation saved the patient from a
perilous position, and probably saved her life. Dr Brewis did
not consider there was more danger in this than in any other
obstetric operation, and on that account he would prefer it in
some cases of abortion. In none of the cases had he found it
necessary to make the posterior incision through the cervix.
V. A CASE OF REPEATED ABORTION DUE TO SYPHILIS ;
TREATMENT BY POTASSIUM IODIDE; BIRTH OF
CHILD WITH CONGENITAL GOITRE.
By B. P. Watson, M.D., F.R.C.S.E., University Gynaecological Tutor,
Royal Infirmary, Edinburgh ; Gynaecologist to the Cowgate Dispen-
sary, Edinburgh.
Four years ago papers were read before this Society by Dr
Angus Macdonald and Dr Fothergill, giving accounts of two
cases in which after the administration of potassium chlorate to
the mothers during pregnancy, children were born with enlarged
POTASSIUM IODIDE, BY DR B. P. WATSON. 205
thyroid glands. About the same time a paper appeared in the
British Medical Journal, by Hewetson, in which he described
the appearances of the much enlarged thyroid gland of a child
born after the administration of potassium chlorate and potassium
iodide to the mother. Cases following the administration of
potassium chlorate had previously been recorded by Sir J. Y.
Simpson in 1855, and Dr (now Sir) A. E. Simpson in 1866.
Apart from these I know of no other cases in which hyper-
trophy of the foetal thyroid, has followed, or been coincident
with the administration of such drugs to the mother during
pregnancy, and this is my reason for bringing the present case
before the Society.
The case has a further interest, in that it shows in a marked
manner the action of potassium iodide in preventing intra-
uterine death of the child in a case of maternal syphilis.
The history is as follows : —
Mrs C, age 27, came to me at the Cowgate Dispensary four
years ago. Five years previously she had been married, and
when pregnant with her first child had been infected with
syphilis. The local manifestations of the disease were very
pronounced, and a considerable amount of ulceration seems to
have occurred. She carried the child to full time, but it died
during delivery by forceps. As far as she knew, it presented
no sign of disease. Her attendant at the confinement informed
her of the nature of her disease, and after the birth of the child
she had sore throat, her hair fell out, and a rash appeared on
the body.
Following in rapid succession after the birth of her first
child she had a series of five miscarriages: the first at the
seventh month, second at third month, third at seventh month,
fourth at three and a half months, and fifth at seventh month.
The seven-months' foetuses were all born in a macerated con-
dition, and had evidently been dead in utero for periods varying
from a week to a fortnight. The patient mentioned that after
206 CONGENITAL GOITRE FOLLOWING ADMINISTRATION OF
each miscarriage she was troubled with a sore throat, and that
her hair fell out much more that usual. I had not previously
heard patients with syphilis complain of this. It looked as if
there were a fresh dose of the poison liberated as each ovum
was cast off. I may say that the husband who infected her had
never been treated.
When I first saw her she was two months advanced in her
seventh pregnancy and was extremely anxious to have a living
child. She was given a mixture containing potassium iodide,
aromatic spirit of ammonia, and infusion of gentian, and in-
structed to take a dose containing 10 gr. of the iodide three
times daily. She carried out the instructions faithfully, and
took 30 gr. of iodide every day right up to the onset of labour.
The course of the pregnancy was normal in every respect, and
her child was born at full time, alive, well nourished, and
apparently healthy. The placenta was large and flabby, with a
few infarcts, but otherwise normal in appearance. In a week
the child developed signs of syphilis, with a character-
istic rash over the buttocks, and snuffles, and a week later it
died. I had not an opportunity of making a post-mortem
examination.
Four months later the patient again became pregnant, and
from the second month onward she took 30 gr. of potassium
iodide per diem. The pregnancy was going on normally up to
the end of July 1905, when she had completed her seventh
month: foetal movements were then strong and the heart
audible. The Dispensary being closed in August, she was given
what was thought to be sufficient medicine to last her over the
month. It had, however, been finished about ten days before
the end of the month, and during that time she had taken none.
She came to see me on 3rd September, and said she had felt no
movements for the past three or four days, and that she feared
the child was dead. Ten days later she gave birth to a
macerated foetus which had evidently been dead for about a
POTASSIUM IODIDE, BY DR B. P. WATSON. 207
fortnight. The placenta was large, and contained many large
infarcts.
In February 1906 she again became pregnant, and the same
line of treatment was followed throughout, viz., the adminstra-
tion of 30 gr. of potassium iodide a day from the second month
up to the time of labour. She carried her child to full time,
had an easy labour, and made a satisfactory recovery.
The child, a male, at birth weighed 6J lbs., and appeared in
every way healthy, except that it had a large swelling in the
neck in the region of the thyroid gland. The two lobes were
equally enlarged, extending up the neck on each side of the
trachea, and there was also considerable thickening of the
isthmus. The swelling did not extend below the level of the
manubrium sterni. There was very considerable embarrassment
of respiration, inspiration being accompanied by loud stridor.
The breathing was always more laboured when the child was
laid on its back, or if the head became extended ; it would then
become extremely cyanosed. It was unable to suckle, and had
to be fed by spoon. For the first fortnight after birth there
was no perceptible change in the goitre, but after that it beo-an
to undergo a slow but progressive decrease in size with a
corresponding diminution in the respiratory difficulty. From
the fourth week the child began to show 'signs of congenital
syphilis. For this, as well as for the obstinate constipation
from which it suffered, it was treated with grey powder. When
three months old there was well-marked cranio-tabes present.
In spite of its obvious syphilitic condition the child throve
fairly well up to the age of three and a half months, when it
developed epidemic cerebro-spinal meningitis. It was sent to
the Eoyal Hospital for Sick Children, under Dr John Thomson's
care, where it died after being ill for ten days. Dr Stuart
M'Donald performed the post-mortem, and to him I am in-
debted for the following notes : —
Thorax. — There is a large goitre present, which measures
208 CONGENITAL GOITRE FOLLOWING ADMINISTRATION OF
about 2\ inches across from side to side. It is compressing the
trachea laterally, is firm and elastic in feeling, and on section
looks like normal thyroid tissue.
Heart. — Some dilatation of right side; no endocarditis;
myocardium soft and flabby.
Lungs. — Both congested and cedematous, with patches of
lobular collapse and emphysema; there is extensive broncho-
pneumonic consolidation of left lower lobe and of upper lobe on
right side. The larger bronchi are congested ; bronchial glands
not enlarged.
Abdomen. — Spleen shows acute congestion, pale ; Malpighian
bodies present.
Ziver. — Cloudy and fatty. Marked inter-cellular cirrhosis.
Bones. — Marrow of ribs red and lymphoid. Marked cranio-
tabes present.
Brain and Cord. — Acute leptomeningitis, basal and vertical.
Convolutions flattened. Great dilatation of superficial vessels.
Exudate most marked in sulci ; yellow in appearance, very like
a pneumococcal case in appearance.
Cord. — External pachymeningitis over lower part of cord;
thick fibrinous-looking exudate present; there is diffuse lepto-
meningitis of cord, exudate resembling that over brain.
The two chief points of interest in the case are : —
1st. The action of potassium iodide in preventing intra-
uterine death ; and
2nd. The enlargement of the thyroid gland of the last child
after the administration of potassium iodide to the mother
during pregnancy.
(1) That the potassium iodide did have an influence in
enabling the patient to carry her children to full time, and that
this was not merely due to the gradual elimination of the
syphilitic poison from her system with the lapse of time, is, I
think, clearly shown by the history of the second pregnancy,
during which she had the drug administered. In the first and
POTASSIUM IODIDE, BY DR B. P. WATSON. 209
third pregnancies under treatment she took 30 gr. of iodide
daily, right up to the onset of labour, and in both cases full-
time, living children were born. In the second pregnancy the
stoppage of the drug for a fortnight at the eighth month was
followed by the death of the child, and I think we are justified
in concluding that the one was a direct result of the other.
It is to be noted, however, that while potassium iodide
seemed to enable the patient to have living children, it did not
prevent the subsequent development of well-marked signs of
congenital syphilis in these children. For this reason I shall,
in future, in cases of a similar kind, combine mercury with
potassium iodide, as is usually recommended.
I gave potassium iodide alone in this case, as in a previous
case of repeated miscarriage with no syphilitic history it had
been successful, the patient having a full-time, living child,
and I thought that it would be doubly efficacious in the present
one. Lomer gives a record of twenty cases of habitual abortion
due to syphilis, albuminuria, and endometritis, successfully
treated by potassium iodide and iron. He supposes that the
iodide acts by preventing placental haemorrhages, which so
often precede the death of the foetus. Other observers have had
good results in similar cases with potassium iodide.
Potassium chlorate is the drug which, on the original recom-
mendation of Sir J. Y. Simpson, is usually employed in non-
syphilitic cases. Its mode of action is still in dispute ; the
hypothesis that it parts with its oxygen to the foetal blood
having been disproved. Fothergill believes that it acts by
preventing excessive clotting in the intervillous spaces of the
placenta.
The apparently equally good results which follow the use of
potassium iodide, even in definitely non-syphilitic cases, seem to
suggest that it is the potassium which is the essential element,
and that the particular salt employed does not so much matter.
This possibility was mentioned by Dr Ballantyne in the discus-
O
210 CONGENITAL GOITRE FOLLOWING ADMINISTRATION OF
sion on Dr Fothergill's paper, and he was led to mention it
from a knowledge of the fact that large quantities of potassium,
together with lime and iron, pass to the foetus in the last three
months of pregnancy. Both potassium iodide and potassium
chlorate are readily diffusible salts, and quickly pass to the
foetus after introduction into the circulation of the mother. In
the present case I had the placenta examined for the presence
of the salt, but none was found, owing probably to the compara-
tively small dose the mother was taking and the rapidity of its
excretion.
It would serve no useful purpose to mention the various
views that are held as to the mode of action of these salts in
preventing intra-uterine death, and I only refer to the possi-
bility of the potassium being the essential element in order to
suggest that in similar cases it might be of interest to try the
effect of some of its other salts, and note whether they were
equally efficacious.
(2) The occurrence of thyroid enlargement in the- last child.
Congenital goitre is, under any circumstances, of comparatively
rare occurrence, so that to find six cases following the adminis-
tration of potassium salts to the mother during pregnancy, for
the prevention of foetal death, seems more than coincidence.
At the same time it is difficult to arrive at any adequate
explanation of them.
In the cases of Sir J. Y. Simpson, Sir A. E. Simpson,
Macdonald and Fothergill, potassium chlorate was the drug
used, in Hewetson's case potassium chlorate and potassium
iodide, and in my own potassium iodide alone.
In none of these six cases was there any history of goitre in
the families, whereas in a large proportion of the other cases of
congenital goitre reported one or both of the parents have been
goitrous. Four of the six cases died shortly after birth as the
result of tracheal compression; and in the two that survived —
Sir A. E. Simpson's and my own — the thyroid underwent a
Hypertrophy of Foetal Thyroid.
[To f<u,t page 211
POTASSIUM IODIDE, BY DK B. P. WATSON. 211
progressive decrease in size from birth onwards — a phenomenon
noted in most cases of true congenital goitre.
In Fothergill's and Hewetson's cases, in which the child
died shortly after birth, detailed reports are given of the histo-
logical appearances of the glands. In the former there was a
large quantity of glandular tissue of an adenomatous type,
with many large blood-vessels in the connective tissue septa.
In the latter the glandular tissue was not so abundant, being
represented by a loose mesh-work of connective tissue, lined by
round and flat cells in one or more layers, but the blood-vessels
were very large and numerous, and Hewetson classifies it under
the vascular or congestive type of goitre, which is the com-
monest type in congenital cases.
In neither case was there any colloid present in the acini.
Although there is no histological report on Macdonald's case,
the fact that there were variations in size within short intervals,
apparently clue to intermittent congestion, probably indicates
that it also belonged to the congestive variety, and from the
description of Sir J. Y. Simpson's case it may also have been of
this type.
In the present case the enlargement of the thyroid is due
to a general parenchymatous overgrowth of the gland. There
is a large quantity of colloid present, the vesicles being widely
distended with it, and a very little inter- vesicular substance is
left. The cells lining the vesicles are low and compressed
looking. In fact, the appearances are exactly those met with
in parenchymatous goitres occurring in the adult (see Plate).
It must be remembered that the present differs from
Fothergill's and Hewetson's cases in that the child was nearly
four months old at its death, whereas theirs were only a few
hours old. In Hewetson's case, moreover, the child was a
seven months one. Then, again, the present child died after
an acute febrile disease lasting for twelve days. What the
exact condition of the gland was at birth can only be a matter
212 CONGENITAL GOITEE FOLLOWING ADMINISTRATION OF
of speculation, but it can hardly have belonged to the vascular
variety of goitre described by Hewetson, as the vessels in it
are not at all numerous, and those present are not large or
dilated. It is more likely that from the first it had been of
the parenchymatous variety.
Such are the facts regarding these cases, but when we try
to arrive at an explanation of them we are met with many
difficulties.
In the first place, it is not possible to say whether the
enlarged thyroid glands of these children were functioning or
not. The absence of colloid in Fothergill's and Hewetson's
cases would lead us to suppose that the glands were function-
less, for it is the colloid which contains the active principle.
But in my own case the presence of colloid does not necessarily
point to functional activity, for colloid may be present and yet
contain no thyroidin, which is the active principle, and without
which the colloid is said to be inert. J. W. Simpson, in a
paper on " The Thyroid Gland in Eelation to Marasmus,"
recently published, points out that though colloid may be
present in the thyroid glands of new-born children, and even
premature infants, it may, on chemical examination, be found
to contain no active principle ; and he believes that new-born
and young infants have little or no efficient thyroid secretion.
In none of these six cases, unfortunately, has any chemical
examination of the gland been made, so that we cannot say
whether the glands were functionally active or not. That is
the first difficulty.
Secondly, granting — which I think we must — that the
hypertrophy of the foetal thyroid following drug treatment of
the mother for repeated abortion in these cases was not a mere
coincidence, two explanations are possible : first, that the hyper-
trophy is due to the action of the drug given ; and second, that it
is due to the condition of the mother's blood, which caused the
abortions and necessitated the administration of the drugs.
POTASSIUM IODIDE, BY DR B. P. WATSON. 213
If Hewetson's and my own had been the only cases of the
kind recorded, we should have been strongly tempted to have
ascribed the thyroid hypertrophy to the administration of
potassium iodide, which is known to have some action on the
thyroid secretion by virtue of the iodine which it contains.
But, in the other four cases, only potassium chlorate was given,
and no iodide. This serves to show how careful we must be in
jumping to conclusions.
On the whole, I am inclined to think that the hypertrophy
is just as likely to be due to the condition of the mother's
blood as to the action of the drug given. Simpson points out
that adults suffering from tuberculosis, alcoholism, and syphilis
almost invariably have sclerosis of the thyroid gland, and that
there is constantly a sclerosis in the gland of children of tuber-
culous mothers. As he puts it, "unhealthy parentage may
produce degenerative changes in the thyroid of the offspring/'
It is possible that in this is to be found an explanation of
such cases as the present one and those previously recorded.
But in the present state of our knowledge of thyroid
physiology, not to mention the diversity of opinion held re-
garding the mode of action of such drugs as potassium iodide
and potassium chlorate, we cannot arrive at any definite con-
clusion as to their true etiology, and must meanwhile be con-
tent with placing them on record.
Eeferences.
Ballantyne. — " Antenatal Pathology." Edinburgh, 1902.
Fothergill.— Edin. Obst. Trans., 1903-1904, p. 41.
Hewetson. — Brit. Med. Journ., 1903, vol. i., p. 657.
Macdonald (Angus). — Edin. Obst. Trans., 1902-1903.
Lomer. — Zeit.f. Geburt u. Gyn., lxvi., Hf. 2.
Simpson (Sir A. K).~Glasgoiv Med. Journ., 1866, p. 181.
Simpson (J. W.).~-~Scot. Med. and Surg. Journ., 1906.
Simpson (Sir J. Y.).— Monthly Journ. of Med. Scien., 1855, p. 350.
214 CONGENITAL GOITRE FOLLOWING ADMINISTRATION OF
Dr Ritchie thought they might congratulate themselves on
having had a most interesting paper, giving one more case in
addition to many already recorded, of the advantage of potassium
iodide in cases where death of foetus occurred in utero.
Dr Watson suggested they might try whether other potassium
salts might not be equally useful. He questioned whether
one was quite justified in making such experiments, when one
knew the great advantage of iodide of potassium as an almost
unfailing certainty. He had listened with great interest to
Dr "Watson's discussion as to the relation of the enlarged thyroid
to the case, and he quite agreed that they could not come to
any definite conclusion as to the precise relation. It seemed
to be quite clear that debility, alcoholism, unhealthy conditions,
were liable, in certain persons, to be followed by some peculiarity
of the thyroid gland.
Dr Oliphant Nicholson thought Dr Watson had contributed
a very valuable paper to the Society, and yet it seemed that, if
possible, he had made an obscure subject still more obscure.
The thyroid gland seemed to have a special affinity for iodine,
which was evidenced by the fact that there was a large quantity
of iodine in the thyroids of animals which were getting
potassium iodide given to them along with their ordinary food.
Iodine was certainly an essential element in the internal
secretion of the gland ; therefore the gland had to rely, in the
ordinary way, upon the traces of iodine contained in the food.
Thus when one gave potassium iodide to a person it might be
assumed that the thyroid activity of that person was increased ;
the gland would pick the additional iodine out of the blood,
and elaborate it into iodothyrin. The remarkable therapeutic
properties of iodide of potassium in so many widely different
pathological conditions were difficult to explain, unless the
drug acted, as had been suggested recently, by modifying the
thyroid activity in some way. Thus iodide of potassium and
thyroid extract were to a certain extent interchangeable
POTASSIUM IODIDE, BY DR B. P. WATSON. 215
remedies in certain diseases. Iodide of potassium was often
given quite empirically, e.g., in very large doses to arrest the
secretion of milk. This was a very precise way of arresting
milk, and it seemed quite probable that the result was brought
about by the iodide producing some alteration in the thyroid
activity. When the thyroid gland became enlarged in a
young person — a parenchymatous goitre —such a condition
certainly occurred in the first instance as the result of a call
by the tissues for an increased supply of thyroid secretion.
He thought it allowable to assume that in the fcetus
the same explanation held good — that for some reason the
foetal thyroid was making an attempt to cope with increased
work. Whether the extra secretion was called for to help the
mother, or to meet some increased strain on its own metabolism,
he could not say. The etiology of simple goitre was still very
obscure ; when occurring in certain districts in endemic form,
it was due to the presence of something in suspension in the
drinking-water of the district. If the people living in that
district drank rain-water, they did not develop goitres. It was
not yet proved whether the substance in the water was organic
or inorganic, but recently Major M'Carrison had shown that
large doses of thymol caused ordinary simple goitres to greatly
diminish in size, and sometimes to disappear. He suggested
that the condition was of bacterial origin. When that point
was ascertained, it might throw further light on the occurrence
of goitre in the foetus. Dr Chalmers Watson had carried out
some interesting experiments in feeding certain animals on an
exclusive meat diet, which might throw some light on these
cases of foetal thyroid hypertrophy. Such a dietary induced a
very marked hypertrophy of the thyroid gland. If the
explanation was that the hypertrophy of the gland resulted
because such a diet contained no calcium salts, it was a matter
of considerable interest. The enlargement of a foetal thyroid
might be connected in some way with a diminished amount of
216 CONGENITAL GOITRE FOLLOWING ADMINISTRATION OF
calcium passing to it from the mother. During pregnancy it
was known that the quantity of lime salts in the mother's
tissues might vary very greatly from time to time. Dr Blair
Bell had shown that the thyroid activity was closely related to
the calcium exchange in the tissues. At present there were
a great many isolated facts about the thyroid gland in relation
to pregnancy and lactation, but it seemed impossible to correlate
them and bring them into line — one fact seemed to be abso-
lutely contradictory to another. Much more light was needed.
He had always used potassium iodide throughout the course of
pregnancy in cases where death of the foetus had occurred, and,
in many cases, with very good results. Sometimes under this
treatment a woman went to full term ; at all events, one was
generally able to prolong the pregnancy till the child was of
viable age. He had never seen an enlarged fcetal thyroid in
these cases, because evidently the necessary factors for its
production had not been present. Dr Watson had added an
important contribution to a very interesting subject.
Dr Keppie Paterson had listened with great interest to the
paper, and also to the remarks of the other speakers. Dr
Nicholson's statement that he had treated several cases all
through pregnancy, but had not found any case of enlarged
thyroid, was an important contribution in itself. Eeferring to
his own experience, he had given up the use of iodide of
potassium. In practice he had attended many women with
syphilitic abortions. They could be placed in two classes. In
some there were definite signs of an attack of syphilis, with
rash, falling out of the hair, and all the usual signs — these
cases were rare; in most cases there was simply a syphilitic
dyscrasia, the patient becoming thinner and weaker, with
perhaps falling out of the hair. This bad state of general
health occurred during a pregnancy and continued after the
abortion or pregnancy was over. He had at first treated
these cases with iodide of potassium, and perchloride of
POTASSIUM IODIDE, BY DR B. P. WATSON. 217
mercury, but had very soon given up the use of the iodide, and
for many years had only given the perchloride of mercury, and
with very great benefit. Patients almost always fattened
upon it, and one was then almost certain that they would carry
to full time and bear a healthy child. How iodide of potassium
or perchloride of mercury acted in the case of syphilis was
probably due to some effect on the opsonins. He related an
instructive case whom he had attended in a few pregnancies.
She had two still-born children, and she came under his care
during her third pregnancy, when he treated her with iodide of
potassium and mercuric perchloride. This child was also still-
born. He advised her to put herself under treatment when-
ever she again passed a period ; this she did, and the treatment
was efficacious, as she gave birth to a living child about full
time, who has never shown any signs of congenital syphilis.
At her next pregnancy she did not begin the medicine until
about the fourth month, and this ended in a still-born child.
Her next conception was treated very early, at the fifth or
sixth week, with perchloride internally, and resulted in a
healthy child. She was again careless at her next pregnancy,
delaying the commencement of the drug, and it again ended in
a still-birth. In most cases he gave -^ gr. of perchloride of
mercury thrice daily, beginning early until after the fourth
month, and then only twice daily. In many cases a course of
mercury during one pregnancy was enough, and subsequent
pregnancies ended in healthy children. In other cases where
there was a bad dose of parasyphilis, and where probably the
husbands had a bad form of syphilis, it was necessary to give
treatment during each pregnancy. He had used the per-
chloride in preference to any other form of mercury, as he had
been taught in Vienna that in whatever form mercury was
administered, even as inunction, it only did good because it
was converted into the perchloride.
Dr Haig Ferguson said that the woman seemed to get a
218 CONGENITAL GOITRE FOLLOWING ADMINISTRATION OF
fresh infection after each pregnancy. Dr Watson had mentioned
that the husband had never been treated for syphilis. He
had seen women treated for years for syphilis with iodide of
potassium and mercury, but he had never seen a case of f oetal
goitre in such cases, though he had seen occasionally goitrous
children without any history of treatment by iodide of potassium.
Dr Keppie Paterson had mentioned the treatment of pregnant
women with mercury, and had spoken of the advantage of
giving the per chloride. He, too, had found that mercury had
a much better effect than giving iodide of potassium alone.
The red iodide of mercury ^ gr. was the preparation he used,
combined with iodide of potassium 5 gr., for the purpose of
dissolving it ; this could be continued for long periods, and he
had found it more satisfactory than the perchloride. He had
had the same experience as Dr Paterson, in finding that
patients taking the mercury became fatter and looked more
healthy and better nourished than before. He added his thanks
to Dr Watson for his suggestive paper.
The President said there were really two points brought out
by Dr Watson very interestingly. The first was, the advantage
of medicines given to the mother during pregnancy in pre-
venting abortion and premature labour in cases of syphilis.
This case had shown the benefit of potassium salts, and although
they did not know how potassium chlorate acted, clinical facts
warranted its use. The second point, as to the relationship
of the enlargement of the foetal thyroid to the condition of the
mother and to the medicine given, was quite a separate thing,
but exceedingly interesting. Personally he had the growing
impression that there was some connection, though it seemed to
be extraordinary. The fact that foetal goitre was rare in the
children of non-goitrous parents must be kept in mind. Six
cases seemed a small number to draw conclusions from ; still it
was a very extraordinary coincidence, if it were simply a
coincidence. There was the argument that iodide of potassium
POTASSIUM IODIDE, BY DR B. P. WATSON. 219
was often given and yet the child was born without any goitre.
That raised the whole question of placental transmission. The
problem of antenatal therapeutics was not so simple. Some
looked on it as giving the drug to the mother and producing
the effect on the child. But in giving the drug to the mother,
it might alter in its chemistry in her stomach, it approached
the uterus through the circulation, in which again it might be
altered; it was almost certain, as demonstrated by modern
research, that the placenta altered things that passed through
it, and it was not simply a question of transudation. It then
reached the foetus, and the foetus itself might have an effect on
it. Antenatal therapeutics was by no means simply a question
of forcing a drug into a patient's stomach in order to have
a definite effect. Another point was, that there was no doubt
that the placenta did sometimes allow substances to pass
through it, and at another time it would block the same
substance, either through some subtle, chemical, or physicial
change in it or in the syncitium. He therefore did not think
it right to exclude the possibility that the drug given to the
mother might have some influence in producing enlargement of
the thyroid, although not doing so in every case. Certainly
every case should be recorded. A suggestion had been made
two or three years ago that they should give mercury in these
cases in the form of the oleate through the vagina, giving it
topically. There were a great many much more favourable
results when the drug was absorbed directly through the tissues,
reaching the placenta and foetus more directly.
Br B. P. Watson, in reply, thanked the Society for the kind
way it had received the paper. There was really nothing he
could add, in reply to the various speakers, to what had already
been said in the paper.
220 EXHIBITION OF SPECIMENS.
Meeting VIII.— July 10, 1907.
Dr J. W. Ballantyne, President, in the Chair.
I. The following gentleman was elected an Honorary Fellow
of the Society: — Dr med. Seichu Kinoshita, Professor of
Gynaecology and Obstetrics, of Imperial University, Tokio,
Japan.
II. Professor Kynoch showed — (a) cervical fibroid, weigh-
ing 12 lbs. The patient, a nullipara, set. 48, had complained
of pelvic discomfort for four years. Menstruation regular till
two years before coming under observation ; since then it had
been irregular. Her chief complaint was intermittent attacks
of retention of urine. On examination, the cervix was found
high up and pressed against the symphysis pubis. The pos-
terior fornix was filled with a hard, fixed tumour, the upper
border of which reached to about 2 inches below the umbilicus.
The fundus of the uterus was felt as a knob-like projection
above the pubes and in front of the cervical tumour. On
opening the abdomen the main tumour was found to be retro-
peritoneal. The posterior layer of peritoneum was opened,
the tumour brought forward, and along with the slightly
enlarged uterus was removed by supravaginal hysterectomy;
the peritoneal opening being closed with a continuous suture.
(b) Uterine fibroid, complicated with pregnancy at the
fourth month, removed by hysterectomy. The patient, eet. 36,
complained of pelvic discomfort and frequent micturition when
about four months pregnant. On examination, the cervix was
found directed to the front, and the fundus reached half-way to
the umbilicus. Through the posterior fornix there was felt a
hard movable tumour connected with the uterus, but much
harder in consistence. Attempts to push the tumour past the
sacral promontory and retain it there failed. As it was obvious
FIVE CASES OF CESAREAN SECTION, BY PROF. J. A. C. KYNOCH. 221
that the fibroid tumour would cause absolute obstruction to the
passage of a viable child, operation was decided on. As the
tumour was fairly movable, and thought therefore to be pedun-
culated, it was hoped that its removal without interference with
the pregnant uterus could be carried out. After its removal,
however, the bleeding from the uterine wound was so persistent
that it was thought safer to complete the operation by supra-
vaginal hysterectomy. Both patients made very satisfactory
recoveries.
III. Dr Ballantyne showed a copy of an edition of the
ByrtTi of Manhynde of nearly one hundred years later than a
copy he had previously shown to the Society.
IV. A SERIES OF FIVE CASES OF CESAREAN SECTION
FOR CONTRACTED PELVIS.
By John A. C. Kynoch, M.B., F.RC.P., F.B.C.S. (Ed.), Professor of
Obstetrics and Gynaecology, University of St Andrews.
Since the opening of the Dundee Maternity Hospital seven
years ago, there have been admitted forty-six cases of con-
tracted pelvis, which have been treated as follows : —
(1) Extraction (breech presentation) . . 1
(2) Spontaneous delivery (two premature labours) 10
(3) Forceps . . . . .9
(4) Version . . . . .4
(5) Craniotomy . . . . .2
(6) Induction of premature labour followed by
symphyseotomy . , . .1
(7) Induction of labour . . . .9
(8) Symphseotomy . . . .3
(9) Cesarean section . . . .7
46
222 FIVE CASES OF CESAREAN SECTION,
In reporting the following five cases of Cesarean section
performed for contracted pelvis, it is interesting to note that
three of the patients belonged to Glasgow, where rickets is so
prevalent, and consequently where so many cases of pelvic
deformity are met with.
The following are the notes of my cases : —
Case I. — J. Y., aged 21, was delivered of her first child
eighteen months before admission to hospital. She had been
thirty hours in labour, when repeated attempts to effect
delivery by forceps in Walcher's position failed. Version was
then resorted to, and a still-born, slightly premature male child
was delivered, there being great difficulty in getting the after-
coming head through the pelvis. She presented herself at the
Dundee Maternity Hospital on 6th December 1903, supposed
to be about eight months pregnant. She was of feeble intelli-
gence, and consequently could give no history relating to her
pregnancy. The date of her last menstruation, and of foetal
movements, could not be ascertained. She was of healthy
appearance; lungs, heart, and kidneys normal. She showed
obvious signs of rickety deformity. Her height was 4 ft. 4 in.,
and there was antero-posterior curvature of both tibiae, less
marked in the bones of the fore-arm. The pelvic measure-
ments were as follows : —
Interspinous . . . .9 ins.
Intercristal . . . 9 „
Diagonal conjugate . . 3f „
True conjugate estimated at about 3 ins. The pelvis was of the
small, flat, rickety type. Judging from the height of the
fundus, the date of pregnancy corresponded to about the end of
the eighth month.
Forceps and version having failed to deliver a living child
BY PKOF. JOHN A. C. KYNOOH. 223
in her previous pregnancy, the alternative methods of delivery
were —
(1) Induction of premature labour.
(2) Craniotomy (in the event of forceps failing at full
time).
(3) Symphyseotomy.
(4) Caesarean section.
Craniotomy was at once excluded, for as Sangar has stated,
" the medical practitioner who does craniotomy on the living
child in a case in which the patient can be removed to a
hospital in order to undergo Caesarean section, with preserva-
tion of the child's life, has fallen behind the requirements of the
times."
The induction of premature labour would have been
almost absolutely favourable for the mother, whilst for the
child the chances would have been almost proportionally
unfavourable, brought up as it would have been in the most
unsanitary surroundings. With regard to symphyseotomy, the
degree of pelvic contraction in this case was perfectly suitable
for this me'thod of delivery. But its immediate mortality is
not any lower than Caesarean section performed under the
most favourable conditions. It permits of, but does not
deliver the child, and it prevents the patient being sterilised, if
this is deemed advisable. With the ever-improving results of
the Caesarean operation, the indications for symphyseotomy
will probably come to be narrowed down to cases where
forceps in Walcher's position fail, instead of being a recognised
method of delivery at a pre-arranged date. The conditions
being favourable, in the interests of both mother and child, for
Caesarean section, and as it was specially desirable in this case
to prevent further pregnancies, I decided to let the patient go
on to full time, and do the operation at a pre-arranged date.
On the 2nd January, the patient having been prepared as for
224 FIVE CASES OF C.ESAKEAN SECTION,
an ordinary abdominal section, and before the onset of labour,
I performed Cesarean section after the method of Cameron.
The child's back was directed to the left side, head presented,
heart sounds distinct. The abdomen was opened in the usual
way, the incision extending from an inch above the umbilicus
to 2 inches above the symphysis pubis. The uterus having
been fixed in a symmetrical position, it was surrounded by
large flat sponges. A flat vulcanite pessary was placed in the
middle line below the fundus, and pressed on, in order to permit
of the uterus being opened with a minimum loss of blood.
The membranes being exposed, the uterine incision was
extended downwards, the membranes ruptured, and the child
delivered head first, the placenta attached to the posterior
uterine wall being easily detached. The uterus was then
turned out of the abdomen, the edges of the incision everted,
and the upper and lower angles compressed by an assistant.
Eight deep and six superficial silk sutures were inserted into
the uterine wound, the mucosa not being included. The
Fallopian tubes were then tied in two places and divided.
The uterus responded well to sponge pressure, and contracting
satisfactorily, it was returned into the abdomen, and the
abdominal incision closed by through and through silkworm
gut sutures. The child, a female, weighing 6 lbs. 12 oz., was
slightly asphyxiated, but soon responded to artificial respira-
tion. With the exception of a rise of temperature to 101° on
the second day, the after progress of the case was an absolutely
satisfactory one. The child was put to the breast at the end
of a week, and was nursed throughout the period of
convalescence.
Case II. — Mrs G-., aged 21, primipara, came under my
observation on the 16th February 1906. She stated that labour
had been in progress for about twenty-four hours, and that the
membranes ruptured soon after labour began. She was a very
BY PROF. JOHN A. C. KYNOCH. 225
small woman, with marked curvature of the bones of the legs.
Her general condition was satisfactory, and beyond a slight
trace of albumen in the urine, the various systems were normal,
pulse 84. Pelvic measurements : —
Interspinous . . . 8J ins.
Intercristal . . . . 8 „
Diagonal conjugate . . . 3 „
True conjugate under . . . 2| „
The child's back was directed to the right side, head movable
above the brim in the transverse diameter, and the os half
fully dilated. Cesarean section being decided on, the operation
was performed as in the previous case. The placenta was
attached to the anterior uterine wall. The child — female —
mature, weighing 6 lbs., was nursed during convalescence, and
both left hospital well, three weeks after operation. It was
ascertained later, however, that the child had died when two
months old.
Case III. — Mrs C, aged 26, ii.-para, was admitted to the
Maternity Hospital on 24th January 1906, at the eighth month
of pregnancy. The history given by her doctor was that she
was delivered of her first child in September 1904. She had
been long in labour before sending for assistance. Attempts
to deliver with forceps having failed, craniotomy was resorted
to, and with great difficulty the child was pulled through the
contracted pelvis. She was sent to hospital as a case suitable
for Cesarean section. She was of healthy appearance, her
height was 4 feet 6 inches. She had a wabbling gait, and there
was slight curvature of the bones of both legs. The pelvic
measurements were as follows : —
Interspinous . . . 7f ins.
Intercristal .... 8-J- „
Diagonal conjugate . . 3 J „
True conjugate . . . . 2| „
226 FIVE CASES OF CESAREAN SECTION,
It was decided to keep her in hospital till full time, and to
operate at a pre-arranged day and hour.
At 10 A.M., on 21st February, and before the onset of labour,
Csesarean section was performed, the steps of the operation
being the same as in the previous cases. After the removal of
the placenta and membranes I passed my finger into the cervix
from above, in order to be satisfied as to the patency of its
canal. This I found to be very considerably stenosed, as a
consequence probably of injuries received during the mani-
pulations necessary to effect delivery at the first confinement.
I then passed a uterine sound through the cervix and closed
the uterine wound. At first there was pretty copious bleeding
through the cervical canal, but with the application of continuous
sponge-pressure the uterus contracted satisfactorily. Both
tubes were ligatured and divided. Ergo tin was given hypoder-
mically immediately before and after operation. The child, a
male, weighed 6J lbs., and left the hospital well.
The patient's condition remained satisfactory during the
first forty-eight hours after operation. After this she got
restless. Pulse became quicker, and she died on the evening
of the fourth day with all the signs and symptoms of septic
peritonitis. At the post-mortem all the uterine sutures were
intact, but the upper two had become infected, as shown by the
presence of pus in their track.
Case IV. — Mrs Nsl primipara, aged 31, was admitted to the
Maternity Hospital at midnight on 27th December 1906,
having been in labour for seven hours. Except for chronic
dyspepsia her previous health had been good, and the examina-
tion of the various systems (beyond a trace of albumen in the
urine) presented nothing abnormal. Temperature normal, pulse
76, and general condition satisfactory. On pelvic examination,
the cervix was found dilated to the size of a five-shilling piece,
membranes ruptured, and the head was lying above the pelvic
BY PROF. JOHN A. C. KYNOCH. 227
brim in the transverse diameter. The pelvic measurements
were as follows : —
Inter spinous . . . .9 ins.
Intercristal . . . 10 „
Diagonal conjugate . . 3J „
True conjugate . . . 2f „
Cesarean section was performed as in the previous cases. The
child weighed 6 lbs., and measured 20 inches. On 31st
January the urine was free from albumen. Both mother and
child progressed favourably, and left the hospital on 5th
February.
Case V. — E. M., primipara, aged 22, was admitted to
hospital in labour on 23rd February 1907. She was of healthy
appearance, her height was 4 feet 3 inches, and there was well-
marked lumbar lordosis and curvature of both tibiae. Examina-
tion of the various systems presented nothing abnormal. The os
was dilated to the size of a half-crown piece, and the membranes
were unruptured. The pelvic measurements were as follows : —
Interspinous . . . .8 ins.
Intercristal . . . 9 „
Diagonal conjugate . . 3 J „
True conjugate . . . . 2f „
Cesarean section was performed as in previous cases. The
child (male) weighed 6 lbs. 12 oz., and measured 19 inches.
Both mother and child made satisfactory recoveries, and
left the hospital on 5th April.
There are a few points connected with this operation which
the experience of these cases suggests. First, a comparison of
the methods of treating the uterus after delivery of the child,
228 FIVE CASES OF CESAREAN SECTION,
and these are — (a) Hysterectomy (partial or complete); (b)
Retention of the uterus, with sterilisation, either by division or
resection of the tubes ; (c) Leaving the uterus without sterilisa-
tion, the true conservative operation. Each method has its
advocates. With regard to the ethics of sterilisation there are
two conflicting opinions. On the one hand, we have authorities
who think that the question is one for the patient to decide ; on
the other hand, there are those who hold that the operator
should restore the patient to as normal a condition as possible,
omitting any method of sterilisation, and repeating the operation
of Cesarean section if occasion should arise. The first case
which I have reported is one where it would have been unwise
to leave the decision to the patient, as her intelligence was so
feeble as to prevent her being able to look after herself properly,
far less a family. The second case, however, where the patient
was sterilised at the time of operation and where the child died
when two months old, would favour the proposal that sterilisa-
tion might with advantage be deferred until a second child had
been delivered by Cesarean section. Granted that the patient
is intelligent enough to understand the situation, and that she
is willing to undertake the risk of a second operation, then
sterilisation may be omitted at the first operation. Many cases
are now reported where the operation has been repeated success-
fully two, three, and four times on the same patient. Yet I
hold that it is not justifiable to endeavour to break the record
of the well-known case of Frau Eittgen, whose pluck in sub-
mitting to Csesarean section five times led to a fatal termination
at the fifth repetition of the operation. In all the cases I have
reported the patients were sterilised by ligature and division of
the tubes. This I consider a reliable enough method, and safer
to the patient than hysterectomy, which 1 think should be
restricted to cases of atony and suspected infection of the
uterus. Another question which suggests itself is, What is the
best time to operate ? In three of my cases labour had already
BY PltOF. JOHN A. C. KYNOCH. 229
commenced, and in two the operation was performed at a pre-
arranged date, and before the onset of labour. Those who
recommend waiting till labour has begun, do so because they
think there is less chance of haemorrhage from uterine atony,
and that a dilated condition of the cervix ensures freer escape
of the lochial discharge. The first fear is groundless, for the
uterus contracts quite as well before as after the onset of
labour. That a dilated condition of the cervical canal is of the
greatest importance, is shown by my unsuccessful case. Here
the cervical canal was so stenosed as only to admit a uterine
sound, and although this appeared to be sufficient to permit of
escape of the lochial discharge, as shown by the occurrence of
pretty free bleeding after the operation, yet I feel convinced
that if dilatation of the cervix up to the size of a two-shilling
piece had preceded Caesarean section, the case would have run
as favourable a course as the others. In my first two cases I
incised the uterine wall between the bars of a flat vulcanite
pessary, as recommended by Cameron, to diminish the haemor-
rhage during the uterine incision ; but I discarded it in my other
cases, and did not find any marked difference in the amount of
bleeding as a result. Further, haemorrhage during the operation
I have found to be best controlled by an assistant grasping the
broad ligaments, and subsequently maintaining uterine con-
traction by sponge-pressure. In all my cases the uterine
incision was a vertical one, and so far as I am aware the trans-
verse incision of Fritsch does not seem to have proved itself in
any way superior. Lastly, with sterilised towels well packed
round the uterus, it is not necessary to adopt Muller's suggestion
of -eventrating the uterus before opening it, as this involves a
very large abdominal incision. But after the uterus has been
emptied of its contents, and as a consequence diminished in
bulk, the introduction of the uterine sutures is facilitated by
bringing the uterus outside the abdomen.
230 FIVE CASES OF CESAREAN SECTION,
Br Barbour said they were very much indebted to Professor
Kynoch for the extremely interesting paper, and congratulated
him very heartily on the success of his cases. In Edinburgh
they had not so many cases of contracted pelvis, and there-
fore their experience in the Maternity Hospital here was
limited. He quite agreed with Professor Kynoch in all the
points he had raised. He thought he was right in saying that
the best time for operation was before labour was begun. He
thought he was also right as to the sterilisation of the patient.
Unless the patient herself was very anxious to undergo the
operation a second time, he thought they ought to do the best
thing for the mother ; and as there was a certain risk in the
operation of Cesarean section, and if they secured the one
living child, they had done all they were justified in aiming at.
With regard to the question of the cause of death in the case
that had died. It was an interesting case. He was not quite
clear that the infection had started from the uterine cavity —
the sutures had not been passed through the mucosa. In all
the cases mentioned, the average amount of the contraction
seemed to be about 2 j inches. He thought Professor Kynoch
was also right in declaring in favour of Cesarean section rather
than symphyseotomy. He had not had any experience of
symphyseotomy, but in one case of pubotomy the convalescence
had been very protracted. Caesarean section was undoubtedly
the preferable operation. He was also interested to hear that
the patients were able to nurse their children.
Dr Munro Kerr had been specially interested in this report
of cases of Cesarean section, because they had so many of
them in the Glasgow Maternity Hospital. It was specially
interesting that three of the cases were from Glasgow. Professor
Kynoch had raised a number of interesting points. He would
be pardoned if he spoke for rather longer than usual on one
or two of the points, for he was now speaking from an experi-
ence of fifty-four cases of the operation. First, as to the time
BY PROF. JOHN A. C. KYNOCH. 231
of the operation. He had not found it had made much differ-
ence whether the operation was performed during or before
labour. In primiparse there had sometimes been difficulty and
discomfort from after-pains, which looked as if the patients
had been suffering from retention of the lochial discharge. So
much had these cases impressed him that in primiparse now he
waited, if possible, till labour had commenced. In multipara
he always arranged to operate before labour had begun. From
his experience he would say that Professor Kynoch was quite
right in saying that after emptying the uterus before labour
commenced there was seldom any bleeding, and in only one of
his cases had there been excessive bleeding that could not be
controlled, and which had necessitated the removal of the
uterus. This case had been brought from the country, some
seventeen miles, and had been in labour some hours before she
started her journey. She was considerably exhausted by the
journey and by continuous uterine contractions. In all his
other cases there had been no post-partum haemorrhage; the
uterus had contracted well. With regard to the abdominal
incision, Professor Kynoch had described what used to be the
custom — making the incision from about an inch above the
umbilicus down to within about an inch of the symphysis.
He thought this was a mistake, and most modern operators
made the incision as high as possible, so as to cut into the upper
part of the uterus and avoid any approach to the lower uterine
segment. With the old incision, in extracting the child, if the
incision was not quite large enough, one might get a nasty tear
of the lower uterine segment. Consequently there was great
advantage in opening the uterus high. Further, with the
high wound there was better union and less chance of hernia.
With regard to the delivery of the child, Professor Kynoch had
mentioned delivery by the head first, but Dr Munro Kerr
had found it much easier to seize the legs and extract by the
legs. A rather important point was the turning out of the
232 FIVE CASES OF CESAREAN SECTION,
uterus before opeuing it, or openiug it as it lay in the abdominal
cavity. He thought what Professor Kynoch had said as to
packing round with towels prevented the necessity of turning
it out at all. If it were turned out, a larger abdominal
incision was necessary. The only cases in which he thought it
was advisable to turn out the uterus were those cases where
the membranes had ruptured some time before. In such cases
it was a distinct advantage to turn it out and pack round with
sterilised towels, and open. In some of these cases he had
actually not removed the placenta through the uterus, but had
pushed it out through the vagina, and as far as possible swept
everything downwards. In opening the uterus, he had quite
given up the pessary. It was really quite unnecessary. It
was of no value where the placenta was attached anteriorly.
It certainly did slightly control the bleeding when the placenta
was attached posteriorly, but was not in the least necessary.
All other writers, in recent years, on Cesarean section, were of
the same opinion. As to the question of sterilisation, it was
very difficult to express an opinion. The ethical question was
a very subtle one, and he was not prepared to take up any
position regarding it. In a sense, as medical men they were not
concerned with anything but doing the best for the patient.
They were not concerned with future pregnancies ; that was for
her husband and herself to decide. He thought there was a
good deal to be said for those who took up the rational position,
and said a woman should not be sterilised. Still, on the other
hand, as an ordinary human being, he felt sorry for a woman
who had to have her abdomen opened several times. There
was no doubt that, if she went on having her abdomen opened
time after time, she would die from the operation ; that is to
say, her chances of dying were increasing each time. It was
not correct to say that one could open the abdomen repeatedly
without opening the peritoneal cavity, because it was shut off
by adhesions. In five or six such cases he had had, in only one
BY PROF. JOHN A. C. KYNOCH. 233
case was the peritoneal cavity completely shut off, and he was
able to open into the uterus extra -peritoneally. In the other
cases it had been quite impossible to open the uterus without
opening into the peritoneum. In this connection he would
mention two patients who had come to him after being
sterilised by having their tubes tied and cut, who had each of
them lost their children. In the first case he had said that
nothing could be done, that there was no further chance of
her becoming pregnant. In the second case he was prepared
to resect the ends of the tied tubes, and try to make a
permanent passage again between the uterus and the ovary.
He had not said this on the off-chance of it being successful,
but because he had seen two cases where the abdomen had been
opened subsequently to Cesarean section in which the tubes
had been tied, and the tubes were found quite patent. The
silk had cut through the tubes, and in both of these cases it
would have been possible to have joined together the ends of
the tubes, with a great probability of establishing a permanent
passage between the uterus and the ovary again. That was his
only reason for sterilising by tying the tubes, and not by
removing the uterus. He did not agree with Professor Kynoch
that it was a safer operation to leave the uterus behind ; he
thought that the safest operation and the one that gave the
best results was that of removing the uterus. In taking away
the uterus, all the dangers of the puerperium were removed,
and the operation was not a difficult one, especially if the
woman was not in labour, and the cervical canal had not
become dilated. If the patient were in labour, and the canal
become dilated, there was a large stump to stitch up and close,
and the operation was then a little more complicated. As
regards the position of Caesarean section and symphyseotomy,
he entirely agreed with Dr Kynoch and Dr Barbour that
Caesarean section was preferable, and" he thought Professor
Kynoch had put the position of symphyseotomy in exactly the
234 FIVE CASES OF CESAREAN SECTION,
right way, namely, that it should be reserved for these cases
where one just failed to deliver with forceps. The amount of
pelvic contraction should be carefully estimated, and then
forceps should be tried, and if one found one wanted a little
more room, then symphyseotomy might be done. He had had
nine cases of symphyseotomy, and had never seen any trouble
afterwards in locomotion, and all the children had been
delivered alive; and only one of his patients had had a bad
urethral tear (a primipara) ; the others had made a satisfactory
recovery. He believed the reason was that he had chosen
these cases with very great care. As to his results from
Csesarean section, the maternal mortality in fifty-four cases
was 5 9 per cent. The foetal mortality — one child had died,
and a second had died in hospital — giving an early and late
mortality of 2 out of 54, or 3*7 per cent.
Dr Lamond Lackie said his experience of the operation was
limited, for though he had assisted several times at the operation
he had had only one case of his own. For that he was indebted
to Dr Haultain, who during his last term of duty at the
Maternity Hospital allowed Dr Lackie to do the operation.
The indication was deformed pelvis, and the conservative
operation was performed. On the following day the patient
had acute pneumonia, and was dangerously ill for a week. The
abdominal wound became septic, and this took months to heal,
but now the patient was well. Dr Lackie agreed with what
had been said about sterilising the patient ; in the majority of
cases it was desirable. He had listened with great interest to
the record of Professor Kynoch's series of cases.
Dr Ritchie asked what sutures had been used.
Dr Kynoch replied that he had used silk.
Dr Munro Kerr used catgut — size 1 or 2 ; at first, catgut
sterilised by Jellett's method — later, Van Horn's.
The President wished to refer to one or two points. As to
closing the incision, long ago they used to have successful cases
BY PROF. JOHN A. C. KYNOCH. 235
with no closure of the uterine incision at all. He remembered,
some years ago, that a writer from Italy sent to him for details
of the operation as performed here, and one of the questions
was as to whether the incision was closed here. He said it
had been a common thing not to close the incision with them,
and the patients had made a good recovery. He had intended
to have dwelt a little on the legal aspect of sterilisation, but as
Professor Kynoch had to leave to catch a train, he would not
now speak upon it.
Professor Kynoch, in reply, said he was very much obliged
to the Fellows who had spoken. He did not read the paper
thinking that he had in so few cases anything original to say,
but because of the opportunity of raising some questions in
connection with the operation. There was one point to which he
would refer regarding his unsuccessful case. Dr Barbour had
asked if his sutures had included the lining membrane of the
uterus. They had not done so, and it was a question whether
the retention of the lochial discharge or infection of the suture
employed was the cause of the sepsis. That would be a point
which would be greatly in favour of sterilisation by means of
hysterectomy. At the same time, Dr Kerr, with his large
experience, insisted upon a certain amount of dilatation of the
cervix, so that this must be a point of great importance in
the success of the operation.
[the "bykth of mankynde.'
236 THE "BYRTH OF MANKYNDE,
V. THE "BYRTH OF MANKYNDE."
(Its Contents.)
By J. W. Ballantyne, M.D., F.R.C.P. (Edin.), F.R.S. (Edin.), Lecturer
on Midwifery and Diseases of Women, Surgeons' Hall and Medical
College for Women, Edinburgh ; Physician to the Royal Maternity
Hospital, Edinburgh j and President of the Edinburgh Obstetrical
Society.
I have already x dealt with the author and the editions of the
remarkable book known as the Byrth of Mankynde ; and I now
intend to complete the consideration of the subject by
discussing the contents of the work and the light thus thrown
upon sixteenth century midwifery. Before I do so, how-
ever, let me remind the reader that Eaynalde's Byrth of
Mankynde is really a composite work, for it contains an English
translation (by Eichard Jonas) of Eosslin's Be Partu Hominis,
along with new matter added by Thomas Eaynalde. It has,
therefore, three component parts : Eosslin's Be Partu Hominis
as translated by Jonas, his additions thereto, and those which
came from the pen of Eaynalde. In such a late edition as that
of 1654, a fourth element is found in the supplementary
matter added by a seventeenth century editor whose name we
do not know ; but it is small in amount, consisting chiefly of
directions for the nursing of children, and no further reference
will be made to it.
For purposes of description I might have taken any one of
the first four Eaynalde editions (those of 1545, 1552, 1560,
and 1565), for it is probable that they all appeared during the
lifetime of Eaynalde;2 but I have chosen that of 1560,
1 Edin. Obstet. Trans., vol. xxxi., pp. 232-270, 1905-06.
2 Raynalde is not likely to have been alive when the 1598 edition
appeared.
BY DR J. W. BALLANTYNE. 237
for it represents what was practically the final recension of the
work, and does not differ (save only in spelling and minor
details) from so late an' edition as that of 1654. The quotations
which occur throughout this article are, therefore, to be regarded
as taken from the 1560 edition except when it is otherwise
stated. At the same time, I shall now and again refer to
differences existing between the various editions, which may
appear to have an interest other than the merely typographical
and orthographical; and I shall draw attention to the very
marked differences which are revealed by a collation of Jonas's
edition of 1540 with those edited by Eaynalde from 1545
onwards. Further, when I reach, in the description, the part
of the book which is a translation of Eosslin's Be Partu
Hominis, I shall devote some space to the consideration of
this German obstetrician's life and work.
The contents of Eaynalde's Byrth of Mankynde, it need
hardly be said, have a special interest for obstetricians. The
book stands, so to say, between the old and the new in
obstetrics : empiric midwifery was, in 1540, beginning to give
way before the advance of scientific obstetrics, although many
years had still to pass before the knowledge of the anatomy
and physiology of labour and the principles of anaesthesia and
asepsis were to sweep away the practices begotten of ignorance
and superstition. The year 1550, in which Pare introduced
podalic version into obstetric practice, has usually been regarded
as marking the separation between the midwifery of the past
and that of the present ; if this be so, then Eaynalde's Byrth of
Mankynde appeared at the very time when the great transition
from the empiric methods of the ancients to the scientific
procedures of the moderns was being brought about. It cannot
fail to be a matter of the most intense interest to know what
were the practices and principles of midwifery in England in
the middle of the sixteenth century, and we find them both
revealed to us in Eaynalde's book.
238 THE "BYRTH OF MANKYNDE,
The Preliminary Matter.
The preliminary matter in a typical Kaynalde edition of
the Byrth of Mankynde (such as that of 1560) consists of the
title page, the Aristarchus preface, and the table of contents.
In the single Jonas edition of 1540 there is the title page, the
religious admonition, the dedication to Queen Catherine, the
table of contents, and a table of weights and measures.
The Title Page differs little, so far as wording is concerned,
in the various editions prior to that of 1654. That of the 1560
edition reads as follows : — " The Byrth of || mankynde, other-
wyse na || med the womans || Booke. || Newly set foorth, corrected
and || augmented: whose contentes ye || may reade in the Table
of the || Booke, and most playne || ly in the Pro || logue. || By
Thomas Kaynalde || Physition || 1560." The titles of the 1545
and 1552 editions are similar, and no alteration of note
appears until 1598, when the title reads: "The birth of
man || kinde, otherwyse || named the Wo || mans Booke. || Set
foorth in English by Tho || mas Eaynalde Phisition, and || by
him corrected, and aug || mented. Whose con || tents yee may
reade || in the Table fo || lowyng: || but most playnely in || the
prologue." One or two slight differences are to be noted in
the editions of 1604, 1613, 1626, and 1634, and then there
occurs the radical change of the 1654 edition (see Plate XIV.
in my previous article, loc. eit., p. 266).
The wording of the title page of the Jonas edition is, as
might be expected, somewhat different : " The Byrth of Man-
kynde, newly translated out of Laten into Englyssha In the
which is entreated of all suche thynges the which chaunce to
women in theyre labor, and all suche inf yrmities whiche happen
unto the Infantes after they be delyuered. And also at the
latter ende or in the thyrde or last boke is entreated of the
Conception of mankynde, and howe manye wayes it may be
letted or furtheryd, with diuers other fruytefull thynges, as
BY DR J. W. BALLANTYNE. 239
doth appere in the table before the booke. Cum privilegio
Kegali, ad imprimendum solum."
The ornamental border of the title page differs greatly in
the different editions which were published before that of 1654,
in which it entirely disappears ; but with this matter I have
already dealt fully in my first article (loc. cit.).
The reverse side of the title page contains (in the 1560
edition) a short Preface, in English, commending the work in
modest terms to midwives and matrons. The same preface
appears in Latin in the 1545 and 1552 editions, and in English
in all the others, but it is not always printed on the reverse
side of the title page. I have reproduced it in Plates II. and
XIII. of my former article, both in its Latin and in its English
form. Since it begins "Albeit some Aristarchus," I have
named it the Aristarchus Preface.
The Aristarchus Preface is absent from the Jonas edition
of 1540 ; but, occupying the corresponding position, there is a
religious admonition which reads as follows (in ordinary
English) : " Unto the Header. An admonition to the reader.
For so much as we have enterprised the interpretation of this
present book, offering and dedicating it unto our most gracious
and virtuous Queen Katherine only, by it minding and tending
the utility and wealth of all women, as touching the great
peril and dangers which most commonly oppresseth them in
their painful labours, I require all such men in the name of
God, which at any time shall chance to have this book, that
they use it godly and only to the profit of their neighbours,
utterly eschewing all ribald and unseemly communications of
any things contained in the same, as they will answer before
God, which, as witnesseth Christ, will require a count of all
their words, and much more then of all ribald and uncharitable
words. Everything, as saith Solomon, hath his time, and
truly that is far out of time, yea and far from all good
honesty, that some use at the common tables and without any
240 THE "BYRTH OF MANKYNDE/'
difference before all companies, rudely and loudly to talk of
such tilings, in the which they ought rather to know much and
say little, but only where it may do good, magnifying the
mighty God of nature in all his works, compassionating and
pitying our even-Christians,1 the women which sustain and
endure for the time so great dolor and pain for the birth of
mankind and deliverance of the same into the world. Praise
God in all His works."
The rest of the preliminary matter of such an edition as
that of 1560 consists of the Table of Contents, as we should
now call it, or, as it is here termed, simply the Table. I have
collated the Contents of the 1545, 1552, 1560, and 1654
editions, and I find them to be almost identical, except, of
course, with regard to the spelling, type, and pagination.
There are, however, one or two small divergences ; thus, in the
editions of 1545 and 1654 there is a heading in the third book
(" Kemedy for the Cramp, or distention of members ") which
does not appear in the other two editions referred to, but the
presence of the heading does not indicate the addition of new
matter in the text; again, in the 1545 and 1552 editions, eleven
Anatomical Figures are named, and nine only in the 1560 and
1654 editions. In the 1560 edition (in my copy at least) the
" byrthe fygures" (seventeen in number or eighteen, if the
" stoole " be counted) follow after the Table of Contents ; but in
several of the other editions they are inserted at the end of the
fourth chapter of the Second Book, their proper place according
to the modern rules of binding.
Before we reach the Table of Contents of the Jonas edition
of 1540, we find additional preliminary matter consisting of the
Dedication. It is so interesting that I reproduce it here in
full. Some parts of it, it may be added, reappear in the
Prologue to the Women Keaders which is peculiar to the
Kaynalde editions. In ordinary English it reads as follows : —
1 Even-Christen or even-Christian meant fellow-Christian.
BY DR J. W. BALLANTYNE. 241
"Unto the Queen. Unto the most Gracious, and in all
goodness most excellent virtuous Lady Queen Katherine, wife
and most dearly beloved spouse unto the most mighty sapient
Christian Prince King Henry the VIII. Eichard Jonas wisheth
perpetual joy and felicity. Whereas of late (most excellent
and virtuous Queen) many goodly and proper treatises, as well
concerning holy scriptures, wherein is contained the only
comfort and consolation of all godly people : as other profane
arts and sciences right necessary to be known and had in use,
have been by the painful diligence of such clerks which have
embusied them in the same very earnestly and circumspectly
set forth in this our vulgar English tongue, to the great
enriching of our mother language, and also the great utility and
profit of all people using the same, and among all other things,
out of the noble science of Physick, have been divers proper
and profitable matters compiled and translated from the Latin
tongue into English, by the reading of the which right many
have confessed themselves to have received great light and
knowledge of such things, in the which they have found no
small comfort and profit. And in this behalf there is in the
Latin speech a book entitled Be Partu Hominis : that is to say,
of the birth of mankind, compiled by a famous doctor in
Physick, called Eucharius, the which he wrote in his own mother
tongue, that is, being a German, in the German speech,
afterward by another honest clerk at the request and desire of
his friend transposed into Latin: the which book for the
singular utility and profit which ensueth unto all such as read
it, and most specially unto all women (for whose only cause it
was written) hath been in the Dutch and French speech set
forth and imprinted in great number, so that there be few
matrons and women in those parts but (if they can read) will
have this book always in readiness: considering then that the
same commodity and profit which they in their regions do obtain
by enjoying of this little book in their maternal language, might
Q
242 THE "BYRTH OF MANKYNDE,"
also ensue unto all women in this noble realm of England, I
have done my simple endeavour for the love of all womanhood,
and chiefly for the most bound service which I owe unto your
most gracious highness to translate the same into our tongue.
Most humbly desiring first your grace's highness, and then
consequently all noble ladies and gentlewomen with other
honest matrons to accept my pains and goodwill employed in
the same : the which thing as I do not doubt for the wont
and incomparable benignity goodness and gentleness inset and
planted in your grace's nature, so shall it be no little encourag-
ing unto me hereafter with farther deliberation and pains to
revise and oversee the same again, and with much more
diligence to set it forth. For considering the manifold daily
and imminent dangers and perils, the which all manner of
women or what estate or degree they be in their labour do
sustain and abide : yea many times with peril of their life, of
the which there be so many examples needless here to be
rehearsed. I thought it should be a very charitable and laud-
able deed, yea and thankfully to be accepted of all honourable
and honest matrons if this little treatise so fruitful and
profitable for the same purpose were made English, so that by
that means it might be read and understanded of them all, for as
touching midwives, as there be many of them right expert,
diligent, wise, circumspect, and tender about such business,
so there be again many more full undiscrete, unreasonable and
far to seek in such things the which should chiefly help and
succour the good women in their most painful labour .and
throngs. Through whose rudeness and rashness only I doubt
not, that a great number are cast away and destroyed (the more
pity). For this cause and for the honour of Almighty God, and
for the most bound service the which I owe unto your grace,
most gracious and virtuous queen, I have judged my labour and
pains in this behalf right well bestowed, requiring all other
women of what estate soever they be, which shall by reading of
BY DR J. W. BALLANTYNE. 243
the same find light and comfort, to yield and render thanks
unto your most gracious highness, wishing greatly that it might
please all honest and motherly midwives diligently to read and
oversee the same, of the which although there he many which do
know much more peradventure than is here expressed, yet am
I sure in the reading of it their understanding shall be much
cleared and have somewhat farther perseverance in the same.
It is no small charge which they take upon them, for if when
any strange or perilous case doth chance, the midwife be
ignorant or to seek in such things which are to be had in remem-
brance in that case, then is the party lost and utterly perished,
for lack of due knowledge requisite to be had in the midwife.
Wherefore I beseech Almighty God that this my simple
industry and labour may be through your grace unto the utility,
wealth, and profit of all English women, according to my utter
and hearty desire and intent, to whom also I daily pray long
to preserve and prosper your most gracious highness, both to
the continual comfort and consolation of our most redoubted
and without comparison most excellent Christian prince, and
also the joy and gladness of his loving subjects. Amen."
Of course, the Table of Contents of the 1540 or Jonas
edition differs much from those of the Eaynalde editions of 1545,
1552, 1560, etc. There is no reference in it to a Prologue, for
no such thing exists in the 1540 issue, unless we regard the
Eeligious Admonition and the Dedication as jointly constituting
one. Then, we note the absence of the first thirteen chapters
of the first Book of all the Eaynalde editions ; and the sixth
chapter of the fourth Book of the Eaynalde editions, contain-
ing the cosmetic suggestions or "bellifying receipts/' is not
represented in the Table of Contents of the 1540 edition.
Eoughly speaking, the Jonas or 1540 edition contains the second,
third and fourth Books of the Eaynalde editions, plus the last
chapter of the first Book and minus the last chapter of the fourth
Book of these later editions. But T have already, in my former
244 THE " BYRTH OF MANKYNDE,"
article, set forth in detail the differences between the Contents
of the two issues (loc cit., p. 248).
In the 1540 edition the preliminary matter closes with two
interesting paragraphs dealing with weights and measures and
with drugs and apothecaries ; they are peculiar to this edition.
The former is introduced in these words : " For because that in
this book many times be found certain measures and weights of
physic, not known peradventure to all such as that chance to
read it, therefore here briefly I have set them forth, showing
the value and estimation of them so far as they shall be
requisite to the better understanding of such things the which
ye shall read in the same treatise." Then follows the table of
the weights and measures, the pound being stated to contain
5,762 grains. The second paragraph refers to the obtaining of
the drugs named in the text of the book, and reads thus : " Ye
shall also note here that many times ye shall happen upon
strange names of such things the which are occupied about
infirmities spoken of in this book, for the which theyr is no
English but are used in their own proper names of Greek or
Latin : and they are such for the most part which are to be had
only at the apothecaries, being of them right well known ;
wherefore when ye shall need any such thing if ye send the
same names in your bill to the apothecaries they will soon
speed your purpose: neither do this if ye may without the
advice of some expert and learned physitian."
I have now enumerated all the parts of the preliminary
matter, both as found in the Eaynalde editions of the Byrth
of Manhynde and in that first edition with which the name of
Eichard Jonas is associated. I now pass to the Prologue,
which is to English readers perhaps the most attractive part
of the work.
DY DR J. W. BALLANTYNE. 245
The Prologue.
To the English obstetrician, as well as to the student of the
manners and customs of the sixteenth century, the Prologue to
the Women Readers will be by far the most interesting part of
the book. It is not a translation of anything in Kosslin ; 1 it
is not indeed a translation of anything at all. We may regard
it as a piece of original writing fresh from the mind of
Kaynalde, giving the history of the work and throwing an
important sidelight upon the way in which obstetric matters
were looked upon in England in the middle of the sixteenth
century. There are, it is true, a few passages in it which are
reminiscent of some parts of the Dedication to Queen Katherine
in the 1540 edition ; but the greater part of it must be ascribed
to Kaynalde.
The intent of the author (" the entent of thauctour ") is to
recite the sum and chief contents of the book, for it is " a great
pricke or allurement, entising and meuinge a man, to reade any
boke, when he is somwhat first admonyshed of the matters
comprehended and contayned therein." Then, without giving
any names, Kaynalde tells how the studious and diligent clerk
[Jonas, to wit] made the English translation of the Latin work
[by Kosslin] entitled Be Partu Hominis, and called it "the
byrth of mankynde" ; it is now to be named "the womans
boke." That translation is now to be corrected and augmented,
revised "from top to to," as the writer quaintly says; and
there are to be " set forth and evidently declared al the inward
partes of women, and that not onely in wordes, but also in
lyvely and expresse figures." Kaynalde beseeches the midwives
who will read his book to pay special attention to these
anatomical matters, for, he adds, " when a person is sycke or
dyseased in any part, it is halfe a comfort, yea halfe his helth,
1 There is a " Prologue "' in Rosslin's De Partu Hominis (edition of
1538, Paris), but it has nothing in common with Raynalde's.
246 THE "BYRTH OF MANKYNDE,"
to understand in what part the dysease is, and howe that parte
lyeth in the bodye."
The second part of his book ("the seconde booke") is to
concern itself with labour, "with the byrth of mankind and
al the daungers, perels, and other cases happenyng to the
labourynge woman at that season." This portion of the work
is to be illustrated with the Byrth Fygures and the picture of
the Womans Stoole ; the first part had the anatomical figures
from Vesalius to elucidate the text.
The third book considers the choice of a wet nurse. " Item
medicines encreasyng, deminishinge, attenuatyng, engrossinge,
and amendynge the mylke in the nources brestes. Also
remedies for manye and sundry diseases, which oft tymes
chaunce unto infantes after theyr byrth."
In the fourth book the author proposes to discuss the
question of conception and the overcoming of sterility. " And
farther in this last booke shall be uttered and set forth certayne
embelleshinge receptes concerning onely honeste and helthsome
decoration and clenlynes." The writer evidently feels that he
is on dangerous ground, for he adds that he is to teach
" nothinge in that place but that onely whiche may make to the
honest, comely, and commendable conservinge and maintaininge
of the inset and natural beautie in a woman, utterly abhorring
and defying all farding, paynting, and counterfeit cast coulors,
which of some dampnable and misproude people be dayly used,
such as by all meanes possible, seke and search more the
abhominable and divilish painting and garish setting forth of
their mortal carcases (the better therby to commend it unto the
eyes of foolish and fond men) than by honest, sober, debonayre
and gentil maners, so to demene their life, that they may
therby rather obtayne the loue, amitie, and hartie perpetual
favour first of god, and then of al honest, discrete, and godly
wise men."
After giving this brief summary of the contents of the book,
BY DR J. W. BALLANTYNE. 247
Kaynalde asks his women readers (" for whose sake and only
respect it is set forth ") to give it their benevolent favour and
good acceptation. He is quite sure, however, that to some the
work will not be acceptable. Not even an invocation of the
gods and goddesses (" great Apollo, wyttye Mercury, and sweet
Suada ") will suffice to convince them who give so " precipitat
and heady judgementes in all maner of matters," that the book
is useful and good. Some will allege " that it is a shame, and
other somme, that it is not meete ne fyttynge such matters to
be entreated of so playnly in our mother and vulgare language,
to the dyshonoure (as they say) of womanhed, and the derision
of theyr wonte secretes, by the detection and disco verynge
whereof, men it readynge or hearing, shalbe moved thereby
the more to abhorre and loo the the company of women." But
it is of no use to attempt to convince such people. Nothing
is so good but it may be abused. Fire and water, meat and
drink, the Bible, even the blessed Sacrament may be abused;
but " to them that be good theimselfe, everye thinge turneth to
good, whatever it be is to them a sufficient matter and occasion
therein to seke the glory of God, and the onely profyte of
their even Christen." " Wherefore," the writer concludes
" consydering that there is nothinge in this world so necessary,
ne so good, holye, or virtuous, but that it maye by wyckednesse
be abused, it shalbe no great wonder though this lyttle booke
also, made, written, and set foorth for a good purpose, yet by
lyght and leude persons be used contrary to godlynesse, honesty,
or thentent of the wryter thereof."
The only possible dangers, so far as the writer can see, are
that some of the medicines referred to may be employed for a
criminal purpose ("some divelishe and lewde use"), and that
the book falling into any " lyght marchauntes handes " may be
used for the derision of women. That men by reading such a
book should " conceave a certayne lothsomnes and abhorrynge
towardes a woman," is answered by the fact that if this were
248 THE "BYKTH OF MANKYNDE,"
so then " Physitians and chyrurgians wyves should greatly be
abhorred and mysbeloved of theyr husbandes " ; and this is not
so. "And I my self likewise, which wryteth thys booke,
should mervaylouslye above many other abhorre or lothe
women." Such " tender reasons " are petty and trifling ; " but
to be short, there is no such thyng, neither any cause thereto
why." In fact, it is rather to be expected that if, by any
chance, a husband read the book, he may, if of a gentle and
loving nature, do his wife good.
Knowing as he does what the perils of childbirth are, the
writer thought " it should be a verye charitable and laudable
dede, and right thankefully to be accepted of al honourable
and other honest matrones, yf by my paynes this lyttle treatyse
were made to speake Englyshe, as it hath been longe syth
taught to speake dutch, frenche, spanyshe, and dyvers other
languages." The Byrth of Manhyde may, if properly read and
consulted, supply the " roume and place of a good mydwife " ;
as a matter of fact, the writer knows that it has been so used
by " many honourable Ladies and other worshipf ull Gentle-
women," and with much profit. But again it has to be
confessed that there are some midwives who would have the
book forbidden, "forsomuch as therein was descried and set
foorth the secretes and privities of women, and that every boy
and knave had of these bookes, reading them as openly as the
tales of Eobin Hood, etc." "But here nowe let not the
good midwives be offended with that, that is spoken of the
badde. For verely there is no science, but that it hath his
Apes, Owles, Bores, and Asses." The good midwives, however,
were glad to get the book. " And thus I conclude and make
an ende of this rude Prologue, requyryng the gentle readers
thereof, that yf they shall fynde anything therein in terpre table
to dyuers senses, to accepte onely that which may make to the
best, accordynge to my meaning."
BY DR J. W. BALLANTYNE. 249
The First Book.
Like the Prologue, the First Book of the Byrth of Mankynde
contains matter which is not to be found in Khodion's De Partu
Hominis. Its contents are mainly anatomical descriptions.
The writer is very sure of the " utilitie of the first boke " ; it is
" as a key, openyng and clearyng the matters to be in treated of
in the seconde." It deals with the "fourme, maner, and
situacion of the inwarde partes of a woman/' with "the
campe or fielde of mankynde to be engendred therein."
An interesting paragraph deals with the relative importance
of the sexes in the matter of procreation : " And although that
man be as principall mouer and cause of the generation : yet
(no displeasure to men) the woman doth conferre and con-
tribute much more, what to the encreasement of the child in
her womb, and what to the noryshment thereof after the
byrth, then doth the man. And doubtlesse yf a man woulde
demaunde to whom the chylde oweth most his generation,
ye may worthily made aunswere that, to the mother : whether
ye regarde the paynes in bearynge, other els the conferrence of
most matter in begettyng."
The organs are then described in detail. First, "the
principal coates of the body " are referred to : they consist of
the superficial skin or cuticula, of the "fleshye" skin or
membrane carnosa, and of the third coat or adeps, which lies
between the other two. "Immediately under the fleshye skin
be conteyned the Muskles." Chapter III. of the First Book is
specially concerned with the " Muskles," and particularly with
those of the " bellye." These are the musculi obliqui descen-
dentes or " the Byaswyse descendyng muskles " ; the musculi
obliqui ascendentes or the " Byaswyse ascending muskles ; " the
musculi recti or " the ryght muskles " ; and the musculi trans-
versi or the " overthwart muskles." " All these f oure Muskles
250 THE "BYRTH OF MANKYNDE,"
be to the entrayles and bowelles within the belly, as foure
seuerall coates: by the vertue and helpe of whom, together
with the ayde of the midwiffe, all expulsion both upward and
downewarde in the guttes, in the stomacke, in the matrix of
the woman in the tyme of labour, and also in the bladder in
tyme of makyng of water, is wrought: and yet besides this
utilitie, they clothe (as I have saide) defende, fortifie, and
strength the inwardes of the belly."
Chapter IV. of the First Book speaks of the " kell, called
Peritoneum," a certain " thin rime " : it " yeldeth unto eche
entrayle a coate and webbe of the cloth of his owne body : by
the whiche his livery, they be the more arctly and straightly
affixed or fastened unto hymselfe." Chapter V. gives the
declaration of the names and nature of the Matrix. "The
Matrix, the Mother, and the wombe, do signifie but one thing,
that is to saye : The place wherein the seede of man is con-
ceaved, fetified, conserved, nourished, and augmented, unto the
tyme of deliuerance, in Latin named Uterus and Matrix."
From the description which follows, it is evident that the
writer intends by "Cervix Uteri" the vulva and vagina.
Chapter VI. deals with " the wombe and his partes." " Nowe
ye shall understande, that the founde or bottome of the
matrix is not perfectly round bowlwyse, but rather lyke the
forme of a mans heart, as it is paynted, sauinge that the
particion or clifte in the matrix betwene both corners, the
ryght and the lefte, is not so profoundlye dented inwardes as
the clyfte in the hearte." From this description it would
almost appear as if the uterus of one of the Mammalia were
intended, or if the writer had come across a case of minor
malformation of the organ (uterus septus) in the human
subject. He is quite sure, however, that there is only one
" holonesse " in the womb ; he does not believe in the seven
"selles" said to be therein. "In tymes passed, dy verse
Clarkes haue written, and many other haue beleued, that
BY DR J. W. BALLANTYNE. 251
there shoulde bee seuen selles, or seuen distinct places in the
Matrix, in thre of the whiche, on the ryght syde shoulde onely
men chyldren be conceyued, and in the other three on the lefte
syde women chyldren, and yf it chaunced that the seede were
conceaued in the seuenth sel, whiche was the myddelmoste,
then that shoulde become a monster, halfe a man, and halfe a
woman. The whiche all is but lyse, dreames, and fonde
fantasyes : for the womans Matrix, as I haue saide, is euen as
a stronge bladder, hauinge in it but one uniuersall holones,
and the chylde when it lyeth in it, lyeth euer on the one syde
more then on the other, the head beynge towardes one of the
corners or angles, and not upryghte towarde the myddle
brydge."
Chapter VI. (VII. correctly) speaks of the " Mother port."
This is the Cervix as we nowadays call it. " It is of the forme
of a haukes bell, or other lyttle mores belles" (i.e., morris
bells). At certain times, "the Matrix beynge apte and
dysposed thereto, and other conditions requisite, thys wombe
porte do naturally open it selfe, attractinge, drawing and
suckinge into the wombe the sede by a vehement and naturall
desyre." During pregnancy it remains closed, "untyll the
tyme of delyueraunce, at what tyme agayne it delate th and
openeth it self, in such amplytude and largenesse, that it is
wonderfull to speake of."
Chapter VIII. contains a description of the vessels of seede,
called the woman's stones, i.e., the ovaries as we now know
them, "wherin is engendred the seede and sparme that
commeth from the woman, not so strong, ferme, and myghtie
in operation as the seede of man, but rather weake, fluy, colde,
and moyste, and of no great firmitie." But, the writer tells
his readers, the woman's seed is just as proper for its purpose
as the man's. "These stones be nothynge so bygge as the
stones of man, but lesse, natter, much fashyoned after the
shape of a great and brode almonde."
252 THE "BYRTH OF MANKYNDE,"
Chapter IX. has to do with the " sede bringers," not, let it
be borne in mind, the Fallopian tubes, but the " two vaynes
and twoo artyres which come to these two stones." Here we
find a description of the blood-vessels of the pelvis along with
the views then held as to the origin of what was called the
" woman's seed," which are set forth at length in Chapter X.
These views have now only an historical interest, for the
physiological knowledge on which they rested has long since
been replaced by more correct information. To the curious,
however, the description given of the four "mines" shops or
workhouses existing in the body cannot but be attractive.
" Of this sort of mines, there be foure principall in the bod ye
of man. The first is the mine of bloud, which is the lyuer, in
whom the iuyce of meate, before of colour whyte, is transmuted
into red, made apt and fitte to nourishe all partes of the body,
attract and drawen out of the stomacke and guttes, thorow
verye small and infinite lyttle vaynes into the lyuer. The
seconde mine is the heart, which of the bloud attracte and
drawen from the great maister vaine, proceading out of the
foresayde lyuer, into his parlers, doth engendre vehement and
liuely spirite, conmixed with depured and greatly elaborated
bloud, within the selles of the heart, from thence sent forth
throw the artires, into all partes of the bodye, being in colour
yealowyshe, thinne, and hoote bloud. The thyrde mine is the
brayne, of whom all the sinewes take thyr originall. In whom
the wyttye spirite, the spirites of mouyng, and the spirites of
al sensibilitie be engendred, and thorow the sinewes sent to all
partes of the bodye. For all suche partes as moue and feele,
haue that by reason of sinewes derived unto those places from
the head. The fourth mine is the stones, in whom by commix-
tion of al the other thre foresaid metalles of the body, that
is to say, vayne bloud, arteriall bloud, and liuely spirites
engendred in the head, is engendred and produced sede, whioh
bestowed in his due place becommeth like in perfection to the
BY DR J. W. BALLANTYNE. 253
creature from whence it came ; that is to say of mankynde,
man." The writer then goes on to explain how " the seede is
receaued into the stones/' how the colour of the seed is trans-
muted, and how the seed in woman is not so firm as in
man, etc.
Chapter XL tells how the seed (of the woman) is sent from
the stones to the angles or corners of the Matrix by means of
a " wormye bodye," evidently the Fallopian tube. The seed in
woman is supposed to be for the purpose of moistening the
genital passage as " with a dewe." The writer then proceeds
to moralize on what he terms the " prickes of nature." " For
yf that the God of nature had not instincted, and insette in
the body of man and woman, such a vehement and ardent
appetite and luste, the one lawfully to company with the
other: neither man ne woman woulde neuer haue ben so
attentyfe to the workes of generation and encreasement of
posteritie, to the utter decaye in shorte tyme of all mankynde.
For ye shal heare some women in tyme of theyr trauayle,
meued through great payne and intollerable anguyshe, forswere
and vowe them selfe, neuer to companye with a man agayne ;
yet after that the panges be passed, within short whyle, for
entyre loue to theyr husbandes, and singular naturall delyte
betwene man and woman, they forget both the sorow passed
and that that is to come. Suche be the privie works of God,
and suche be the prickes of nature, which neuer createth no
special pleasure unaccompanyed with some sorow: neither is
there for the most part any sorow, but that it hath annexed
some ioy or comforte, lesse or more, to alleuiate and lyghten
the burthen and weyght of displeasure."
Chapter XII. deals with the bladder in women, with stone
(" but women be not so prone ne apt to engender the stone in
the bladder as men be "), and with the reason why the urine
when it has reached the bladder does not revert again.
Chapter XIII. is a very interesting one, for in it are con-
254 THE "BYKTH OF MANKYNDE,"
sidered not only the " vaynes which resort to the Matrix/' but
also " the termes and theyr course with the causes thereof."
" Nowe to come to the declaration of the nature of termes, ye
shal understand that thei be called in Latine Menstrua, for
because that ons in a moneth they happen alwayes to woman-
kynd, after XIII. or XV. yeares of age passed (beynge in theyr
perfect health) : In Englyshe they bee named Termes, because
they retourne eftsoones at certayne seasons, tymes and termes."
Having described, as best he knew, how the blood was poured
into the Matrix, the writer goes on to tell the cause of the
terms, that they are really intended to serve as nourishment
for the foetus ("feature"); for "prudent Lady nature" has
wisely so provided ; " yea, although the woman do neuer
conceaue .... yet is there no faute in nature, who hath
prepared place, and foode to be at al tymes in readynes." It
is noted, also, that women that have no terms cannot bear
children ; that the terms do not follow the waxing and waning
of the moon exactly ; and that the duration of the flow varies
in different women.
In Chapter XIV. are considered at some length the three
cauls or wrappers "wherein the infant is lapped" in the
uterus. The innermost caul is named the Amnios, " in Latine
Agnina, for cause it is as dilicate as lambes bee." " The
mydwifes commonly call it the coyfe or byggyn of the chylde,
and some call it chyldes shert, the which also many times
proceadeth alone with the chylde, eyther uppon the chyldes
head, or one of the armes or legges. And then the women
reserve it as a thynge that shoulde betoken some grat lucke to
the chylde in tyme to come." "The seconde wrapper or
caule in Greek is called Allantoides, in Latine Farciminosa, in
Englyshe these two termes do signifie haggiswyse for because
that it is fashioned much after the shape of the outwarde
skynne or bagge of an haggisse puddinge." This second caul of
Eaynalde is our modern chorion apparently, while the third
BY DR J. W. BALLANTYNE. 255
which he names Chorion or Secundina (or hoop caul) would
seem to correspond to the placenta; but the description is
vague and shows no evidence of close observation of nature.
The description of the vessels of the umbilical cord is more
exact. " Thorow these Ar tires, liuely spirite and freshe ayre
is deriued out of the mother into the chylde, wherwith the
naturall heate of the chylde is viuified and refreshed. And
these two Artires with the foresayde nauyll Vayne, when the
childe is borne, begin to wyther and drye, euery day more and
more, and become much like a harpstryng, without any holow-
nesse or cauitie." The urachus ("another vessell") is also
described, and it is said that by it the urine passes from the
bladder to the space between the first and second caul without
the child's body. The placenta (" chorion ") is compared to the
spleen or melt " in a man or beast " ; " so that to be short,
Chorion is the immediat receptacle and receauer of al the
vaynes and artires, to be deduced from the Matrix to the
chylde, and the chylde recaueth onely at his hand the two
Vaines and Artires, whiche by the way as they passe and perse
thorow the other two caules, towardes the chyldes Nauyll, they
sende into eche of the caules innumerable small eye vaynes
and artires, whereby the caules be sustayned and encreased
also."
The terms, when there is a foetus in the uterus to be
nourished, are no longer superfluous but are used in supplying
nourishment to the infant in utero, and that part which is not
needed goes to the breasts to become milk. It is not right to
regard the terms as a purgation, for the blood of which they
are composed is as pure and wholesome " as all the reste of the
bloud in an ye part of the body els." " Yet much more are to
be detested and abhorred, the shameful lyes and slaunder that
Plinie, Albertus magnus de secretes Mulierum, and diuers other
mo haue written, of the venimous and daungerous infective
nature of the womans Flowres or Termes : the which all be
256 THE " BYRTH OF MANKYNDE,"
but dreames and playne dotage. To rehearse theyr fond wordes
here, were but losse of inke and paper, wherfore let them passe
with theyr auctours." It is not a little amusing to read such
denunciations of Pliny and Albertus Magnus following so
closely after some of the anatomical descriptions that have
gone before; but in his views upon the functions of the
placenta as set forth in the following paragraph the writer
is far in advance of his time. " Forbecause that she (Nature)
woulde that the pure bloud commyng from the Matrix vaynes,
should be made yet purer, she suffereth not the same to entre
immediately into the infante, but first useth another meane,
and sendeth it into Chorion or the hoope call (as I haue sayd
before), where truely it hath a certayne circulation, and another
digestion, wherby it is desecate, and clensed very exquisitly,
by the diligentis of nature attenuated and fined, and so at the
laste sent foorth into the infant, leauyng all the grosser part
in the spungye bodye of the hoope caule." (It is to be re-
membered that the hoop-caul is the placenta.)
The Fifteenth Chapter is concerned with some curious
considerations regarding which of the three Matrix veins
contain the Terms and how the milk comes to the woman's
breasts. The importance of knowing which of the veins
contain the menses is, the writer thinks, at once evident when
we have to deal with too much or too little monthly flow ; to
put these anomalies right we have to apply medicines, and if
the menses come only from the veins of the neck of the womb
there will be no use in applying medicines to those of the
fundus. The writer is of opinion (for reasons which it is
unnecessary to discuss now) that the terms come from the
veins at the fundus only. It is in this connection that the
writer relates the history of two cases in his practice, the one
in London and the other in Paris, to which reference has
already been made {Edin. Obstet. Trans., vol. xxxi., p. 243,
1905-06.)
Fig. 1.
Illustration taken from Vesalius's De Hurnani Corporis Fabrica
(Edition of 1543), where it is the Twenty-fifth Figure of the
Fifth Book ; it appears as the Second Figure in the Byrth
of Mankynde.
[Between pages 256 and 257.
Fig. 2.
Illustration taken from Vesalius's De Hwmani Corporis Fabrica (Edition of 1642), showing
the Nine Figures which were used by Raynalde to illustrate the Anatomical Part of
the Byrth of Mankynde.
hm^
It,
v
Fig. 3.
Figure from Vesalius's De Humani Corporis Fabrica (Edition of 1543), representing the
Dissection of a Man's Body. It appears as Fig. 1 of the Anatomical Figures of the
1545 and 1552 Editions of Raynalde's Byrlh of Mankynde, but is omitted from that
of 1560 and from all subsequent ones.
Fig. 4.
Figure from Vesalius's De Humani Corporis Fabrica (Edition of 1543),
representing the Dissection of a Man's Body. It appears as
Fig. 2 of the Anatomical Figures of the 1545 and 1552 Editions
of Raynalde's Byrth of Mankynde, but is omitted from all the
subsequent ones.
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Fig. 9.
Figure of Twins in Utero, from Rhodion's Be
Partu Hominis (Edition of 1538), where it
appears on folio 29.
Fig. 10.
Figure of Double Monster in Utero, from Rhodion's
Be Parlu Jlominis (Edition of 1538), where it
appears on folio 11.
BY DK J. W. B ALLAN TYNE. 257
There is much else in this chapter about clots in the terms,
about the " white flowers," about retention of the terms, and
about the manner in which " the mylke which commeth to the
brestes is engendred of the Termes (accordyng to moste mens
opinions)." There is not wanting evidence, it is pointed out,
of the "great familiaritie betwene the Matrix and the brestes,
for so much as the ebbyng of the one is the flowinge of the
other."
Such are the matters dealt with in the First Book of the
Byrth of ManJcynde in the 1560 edition; it remains for me now
to examine the differences which exist between this and other
editions. The 1545 and 1552 editions call for no special
comment, and those that were published later than 1560 also
show none other than trifling alterations; but the Jonas or
1540 edition differs widely from the rest.
The First Book of the 1540 edition is really the Second
Book of the Kaynalde editions (with some exceptions to which
reference will be made), and the First Book of the Eaynalde
editions finds no counterpart, or almost none, in the 1540
edition. Almost none, for the First Chapter of the latter
contains an account of "how many caules the birth is
compacted and wrapped in," and the fourteenth chapter of the
Eaynalde editions deals with "the three caules or wrappers
wherein the infant is lapped." Chapters I. to XIII, Chapter
XV., and part of Chapter XIV. of all the Eaynalde editions
find no counterpart in the 1540 edition of Jonas; practically
the whole of the First Book of the Eaynalde editions, therefore,
is new material added to what was in the 1540 edition. To
trace the source or sources of the new material found in all the
Eaynalde editions would be an interesting literary investigation,
but it is one which I am not now in a position to make. I
may, however, state that no part of the added chapters is in
the two editions of Eosslin's De Partu Hominis which I have
been able to examine (those of 1538 and 1556); and in the
R
258 THE "BYRTH OF MANKYNDE,'
meantime it is only reasonable to ascribe it to Raynalde, and
to regard it as part of the " augmentation " mentioned on the
title page of the 1545 and subsequent issues of the Byrth of
Manhynde.
The Anatomical Figures.
At the end of the First Book is " The declaration by letters
of the fygures folowing, wherein be set forth to the eye euery
parte in woman mentioned in thys boke before: Which in
the former Printinges hath ben corrupted, but nowe truely set
forth." These figures are nine in number, and they have all
been reproduced in Plates IV., V., VI., and VII. of my former
article.
No indication is given in the letterpress as to the source of
the illustrations ; indeed from the reading of the accompanying
descriptions it would seem that they were original, and that
the objects depicted in them had been seen by the writer. A
little investigation, however, soon shows that this was not the
case. None of them is to be found in the 1538 edition of
Rosslin's De Partu Hominis, although four of them make their
appearance in the 1556 edition ; but, then, as we shall see, they
had already appeared in the 1545 edition of the Byrth of
Manhynde and had been repeated in the 1552 edition. Evidently,
therefore, their original source is not Rosslin's work. As a
matter of fact, they have been taken, description and all,
from Vesalius's book De Humani Corporis Fabrica, in the
"first" or 1543 edition of which they are all to be
found.
I have carefully compared the plates in the 1560 edition of
Raynalde's Byrth of Manhynde with those in the 1543 edition
of Vesalius's work, with the following results : — The first figure
in Raynalde is the twenty-fourth of the Fifth Book of Vesalius,
and is found on p. 377 of that work, with the descriptive letter-
BY DR J. W. BALLANTYNE. 259
press on pp. 376, 377, and 378 ; the second figure is the twenty-
fifth of Vesalius, and is found on p. 378, with its description on
pp. 379 and 380 ; the third figure is the twenty-sixth of Vesalius
on p. 380; the fourth figure (IIII.) is also to be found in
Vesalius's work at the end of his Third Book, on p. 313,
with its description; Figures V., VI., VII., and VIII. of
Eaynalde's work are the first, second, third, and fourth
separate figures in the thirtieth plate of Vesalius's Fifth Book,
and are to be seen on p. 382, with descriptive notes on p.
383; and the ninth figure of Eaynalde's Byrth is the
twenty-seventh of the Fifth Book of Vesalius's Be Humani
Corporis Fabrica, where it is to be found with its description
on p. 381.
All these figures, as they appear in the 1560 edition of
Eaynalde have been reproduced in my former article, where they
are numbered Figs. IV., V., VI., and VII., but, in order to pre-
vent confusion, their proper numbers (I., II., III., IIII., V., VI.,
VII., VIII., and IX.) are also attached to them (although some
of them were reversed in the original printing, e.g., IV., VII.,
and IIIV. for VI., VII., and VIII.). In order that the reader
may compare the plates as they appeared in Vesalius's work
with their reproductions in Eaynalde's 1560 edition of the
Byrth, I give here Vesalius's twenty-fifth figure corresponding
to Eaynalde s Fig. II. (Fig I.) : it can be studied alongside of
the Eaynalde reproduction (Fig. V. of my former article).
Further, in a later edition of Vesalius's work (that of 1642)
all the nine figures used by Eaynalde were grouped
together in one plate (on p. 96), and I have thought it
worth while to reproduce this also (Fig. II.). It represents
in graphic form Eaynalde's unacknowledged indebtedness to
Vesalius.
The descriptions of the figures are literal translations of the
Latin text which accompanied the illustrations in Vesalius's Be
Humani Corporis Fabrica. I give here in parallel columns
260
THE "BYRTH OF MANKYNDE,'
the Latin description of Figure II. and the English translation
of it:—
A praesentis figurae dextra
mamilla cutem abstulimus, ut
quam fieri posset proxime mamil-
larum natura hie oculis subji-
ceretur. Deinde ventriculum, et
cum intestinis mesenteriuin et
lienum resecuimus, recto interim
intestino non secus quam in mox
praecedente figura relicto. Ad
haec, uterum suo extimo quod
peritoneum ipse porrigit involucro
quodammodo spoliavimus, omnes
membranas quam licuit accura-
tissime passim, ideo amputantes,
ut seminis materiam testibus
def erentia et rursus semen ab his
utero deducentia vasa in con-
spectum venirent. Vesicam vero
deorsum in sinistrum latus reflexi-
mus, una meatum a dextro rene
ipsi urinam deferentem abrum-
pentes, ut urinam vesicae depren
tium meatuum insertio appareret,
ipsaque vesica uteri inspectionem
non occuparet. Postremo pubis
ossium portionem ab hac figura
exsecuimus, quo uteri cervix ac
vesicae etiam collum apposite
viderentur.
We have here taken away the
skyn from the ryght teate of this
present figure, that the nature of
the teates mighte as nygh as may
be, be set before the eyes, and
afterwards we have cut awaye
the ventricle with the bowels, and
also Mesenterium and the splene,
leaving the strayte entrayle in
thys place unmedled with, as well
as we dyd in the fygure before.
And moreover, we have as it were
taken awaye from the uttermooste
cote which Peritonium gave unto
it, cutting away also al the pan-
nicies, that the vessels caryinge
forth the substaunce and matter of
sede to the stones, and also the
vessels carying away the sede
from thence to the Matrix shoulde
appeare-and bee seene. Also we
have tourned over the bladder
downewarde on the lefte syde,
lykewyse breaking the way or
conduite which beareth foorth
the urine to it from the ryght
kydneye, that the insertion of the
wayes of bearyng forth the urine
to the bladder myght appeare, and
that the bladder shuld not let the
inspection or sight of the Matrix
or Wombe. Last of all we have
cutte away from this fygure a
portion of the bones above the
privie membres, thot the neckes of
the matrix and of the bladder might
the more commodiously be sene.
BY DR J. W. BALL ANT YNE. 261
The comparison of the Latin description with the English
translation leaves no donbt that Raynalde boldly appropriated
both the plates and their accompanying text from the work of
Vesalius ; he was not even at the trouble of altering personal
details which referred to Vesalius, such as the allusion to his
work at the University of Padua which occurs in the explana-
tion of the ninth figure. In this respect, however, he did not
differ from the editor of some of the later editions of Rhodion's
Be Partu Hominis {e.g., that of 1556), who also borrowed some
of Vesalius's plates without acknowledgment.
What has been said above refers to the 1560 edition of
Raynalde's Byrth of Mankynde. When we turn now to the
1545 and 1552 editions we find two other anatomical figures
(making eleven in all), named the fyrst and second fygures,
along with several differences in the accompanying descriptive
letterpress. The wording of the Declaration differs slightly,
the reference to corruptions in the printing not appearing. It
reads: "The declaration by letters of the fygures folowyng,
wherein be set forth to the eye every part in woman mencioned
in thys Boke before." The first and second figures, however,
represent dissections of a man's body, and at the end of the
descriptive letterpress the editor somewhat ingenuously says :
" Here ye shal be advertysed that although these ii fyrst fygures
be made principally for ye man, yet may they serve as wel
to expresse the woman : for the man and woman differ in
nothyng but in the pryvie partes." These two illustrations also
are borrowed from Vesalius's Be Humani Corporis Fabrica,
where they appear on pp. 355 and 356 of the 1543 edition, and
are named the first and second figures of the Fifth Book. They
are reproduced here as Plates III. and IV. I place, again in
parallel columns, the Latin and the English, and it will be noted
that the latter is not so strictly a translation of the former as
in the descriptions of the 1560 edition : —
Praesenti figura tanta humani In the fyrst fygure is set forth
262
THE "BYRTH OF MANKYNDE.
corporis portio delineatur, quanta
ad peritonaei sedes ostendendas
sufficit : exprimitur itaque hac
figura anterior peritonaei sedes,
sectionis serie ab octo abdominis
musculis libera, nullaque ex parte
dissecta.
A,A,B,C,D. His characteribus
peritonaeum insignitur, quodamo-
doque hac figura terminatur.
E,E. Linea a mucronata pecto-
ris ossis cartilagine ad pubis usque
ossium commissuram procedens,
cui oblique descendentium et as-
cendentium, et transversim pro-
cedentium abdominis musculorum
nervosae tenuitates pertinacissime
connas-cuntur.
F. Umbilicus, quern inter dis-
secandum etiam adeptis abdominis
musculis, gratia opportunae um-
bilici vasorum demonstrationis,
reservare solemus.
G. Seminaria sinistri later is
vasa suis membranis, quas a peri-
tonaeo mutuantur, adhuc obvoluta.
H. Seminaria dextri lateris
vasa.
I. Vena ac arteria quae potis-
simum inferiori sedi rectorum
abdominis musculorum exporri-
guntur, quorum et hie quoque
l>ropendet portio.
K. Vena et arteria, quae sub
osse pectoris exporrectae, in an-
teriorem abdominis sedem prola-
buntur, praecipue rectis abdominis
oblatae musculis, ac superiore ab-
dominis sedem universam quoque
implicates : quemadmodum illae
so moch of a man's body as may
be sufficient to show the forme
of thee kell called Peritoneum :
spoken of in the iiii Chapter,
Whose compasse is here noted
wyth A,B,C,D.
A,A. Noteth the grystell, nether
ende or poynt of the brest plate,
in the pyt or pitch of the brest
agaynst the stomacke.
E,E. is a lyne descendyng upon
Peritoneum from the sayde grystle,
downe to the myddle joynt of the
share bone.
F. is the navell.
G. sygnifieth the sede vessels of
the lefte syde in men descendynge
out of the amplytude of the
bellye.
H. is the ryght seede vessell :
but thys G. and H. hath no place
in the women.
I. sygnyfieth the ascendinge
vayne and arty re mencyoned in the
last chap.
K. the descending brest vaynes
and artyres spoken of in the same
Chapt. as for other letters that be
in this figure I wyl make no
further declaration of them, for
because they serve nothing to this
present purpose.
BY DR J. W. BALLANTYNE. 263
quas insignivimus, humiliore et
pubis ossibus viciniore implicat.
L. Venarum soboles in peri-
tonaei latera excurrentium, ac ab
illis venis deductarum, quae aut a
conjuge carente vena, aut geni-
culatim a cava pronascuntur, qua
ipsius caudex lumborum vertebris
colugatur, etc.
Other differences between the edition of 1560 and those of
1545 and 1552 remain to be noted. These consist chiefly of
verbal differences in the descriptions of the figures. Figures 3,
4, 5, 6, 7, S, 9, 10, and 11 of the earlier editions correspond to
Figures 1, 2, 9, 3, 4, 5, 6, 7, and 8 of the 1560 edition. To
show the extent of the verbal changes I place here in parallel
columns the description of the fifth figure of the 1552 edition
and the ninth figure of the 1560 edition; they represent the
same specimen, but, as will be seen, differ considerably : —
1552 Edition. 1560 Edition.
This 5 fygure is pourtrayed after And the nynth figure sheweth
ye quycke, bothe in length and the Matrix cut forth of the body,
bredtli, according to the length being of that bygnesse as it was
and bredth of the matrix of a sene taken foorth of a woman at
woman which was cut open for the the laste Anothomye, which I dyd
same purpose by phisitions. But se at the universitie of Padua in
ye must understand that here ye Italy. And moreover we haue so
founde or body of ye wombe or devyded and cutte a sunder the
matrix is devyded in ye myddes : bottome of the Matrix by the
the forepart of the which, is turned myddle, that the concavitie and
up, for because that ye maye the hollowe bought within the same
better perceave ye cavite of the myght be perceaved, and the thicke
matrix signed, the uppermost with substaunce also of both the coates
A.A.C. The nethermoste halfe of the Matrix in women, when
wyth B.B.D. Item. C. in the they be not with chylde.
uppermost halfe and D. in the A.A.B.B. The concavitie and
nethermost halfe show the seame holowe bought of the bottome of
or lyne spoken of cap. vi. E.E. the Matrix.
264
THE "BYRTH OF MANKYNDE,
both in the upper and also in the
nether betoken ye crassenes or
thickenesse of ye inner coate, wall
or skyn of the matrix in wemen
not beinge with chyld, through
the contraction thereof as ye shall
farther rede in the sayd. vi chapt.
F.F. the propendynge or heldynge
parte of the seme in the matrix
spoken of. cha. vi. G.G. is the
porte, oryfyce, or gate of the
wombe. H.H. is the second and
utter coate of the matrix geven to
it from Peritoneum. I.I. on both
sydes of the necke of the matrix,
do sygnifie, part of the kel called
Peritoneum, sticking yet to the
sydes of the Matrix and the
necke thereof. K.K. is the place
where the matrix is fastened to
the upper part of the privy
passage, ca. vii. L. signifieth
the stub of ye bladders necke,
wher it entreth into ye forepart of
ye privy passage.
CD. A line somewhat after
the maner of a seame called in
Latin Scortum, which doeth be-
longe to the place wherein the
testycle doo lye, whiche swelleth
somewhat foorth into the bought
of the bottome of the Matrix.
E.E. The thickness of the inner
and proper coate of the bottome
of the matrix.
F.F. A portion of the inner-
more bottome of the Matrix, swell-
yng foorth downeward from the
hygher seate of the Matrix, into
the holownes and bought of the
bottome.
G.G. The beginning of the
necke or the opening place of the
bottome of the Matrix.
H.H. The seconde or uttermore
infolder of the bottome of the
Matrix, descended from Peri-
toneum.
I.I. Here we have reserved a
portion on bothe the sydes of the
thinne coverynges, descended from
Peritonium, and conteynyng the
Matrix.
K. Here is also sene the sub-
staunce of the necke of the Matrix,
because the cuttyng wherewith we
devyded the bottome of the Matrix,
was begunne at this place.
L. A part of the necke of the
bladder, implanted into the necke
of the Matrix, castynge foorth into
it the urine. The swellyng partes
of Abdomen and whatsoever is els
to be considered thereof, they may
be sufficiently knowen without
derection of Karacters.
BY DR J. W. BALLANTYNE. 265
On comparing these two descriptions with the original
Latin inscription found in Vesalius's work, I find that the first
is a free and the second a literal translation thereof. In the
first (that of 1552) all mention of Padua is omitted, while in
the second (that of 1560) it is referred to, with the addition of
the words "University of" and "in Italy," which are not in
Yesalius's text. On the whole, we must accept as substantially
correct the statement made in the 1560 edition, that "the
declaration of the fygures ... in the former Printinges hath
ben corrupted, but is nowe truely set forth," if by that is
meant a closer adherence to the text of Yesalius's work.
The Jonas edition of 1540 is supplied with no anatomical
figures.
The Second Book.
The contents of the Second Book (of all editions subsequent
to that of 1540) are of less interest to English obstetricians, for
they are simply a translation, rather free perhaps, of Ehodion's
book Be Partu Hominis. I shall first enumerate the subjects
dealt with in this Book, taking again the edition of 1560 as the
standard Eaynalde one, and I shall then compare the matter as it
appears in the various editions, and consider the character of the
translations with which Jonas and Eaynalde have furnished us.
The first chapter of the Second Book of the 1560 edition
(and of all the others, except that of 1540) corresponds to the
second chapter of the work of Ehodion (which is not divided
into " Books," but simply into twelve chapters).
Chapter I. begins with a short paragraph summarizing the
contents of the First Book, and then proceeds to deal with " the
tyme of byrth, and which is called naturall or unnaturall." The
premonitory signs of labour are named : " first certaine dolours
and paines begin to growe about the guttes, the Navyll, and in
the raynes of the backe, and lykewyse about the thyghes, and
the other places beynge neare to the privie partes, which lyko-
\
266 THE "BYRTH OF MANKYNDE,"
wise then beginneth to swell and to burne, and to expell
humours, so that it geveth a plaine and evident token that the
labour is nere." Then comes a definition, which at least does
not err by entering too much into detail : " Naturall byrth is
when thy chylde is borne both in due season and also in due
fashion." The due season is " most commonly after the ninth
moneth, or about fortie wekes after the conception " ; and then
follows that oft-repeated and widely-believed statement about
the poor chances of survival which an eighth month child has
as compared with one born at the seventh month (when " the
chylde proveth very well "). The writer is somewhat in error
when he describes the " due fashion " : " first the heade
commeth forwarde, then foloweth the necke and shoulders, the
armes with the handes lying close to the body towardes the
face and forepart of the chylde, beyng towardes the face and
forepart of the mother, as it appeareth in the first of the byrth
figures." This definition makes, therefore, a face to pubes case
the natural one, which is, of course, an error. The author
(Rhodion) is on safer ground when he states that " yf the byrth
be naturall, the dely veraunce is easy without longe tarying or
lokynge for it." The " byrth not natural is, when the mother is
delyvered before her tyme, or out of due season, or after anye
other fashion then is here spoken of before : As when both the
legges proceade fyrst, or one alone, with both the handes up, or
both down, other els the one up and the other downe, and
dyvers otherwyse, as shalbe hereafter more clerely declared."
The "other els" as stated in the next chapter is " sidelonge
(the which is most perellous) or arselonge, or backlonge, other
elles (havinge two at a byrth) both proceade with their feet
fyrste," etc.
Chapter II. deals with "easy and uneasy, difficult, or
dolourous deliveraunce, and the causes of it : with the signes
howe to knowe and foresee the same." " Verye manye," says
the writer, "bee the perylles, daungers and thronges, which
BY DR J. W. BALLANTYNE. 267
chaunce to women in theyr labour, which also ensue and come
in dyvers waves, and for dyvers causes, such as I shall here
declare." Among the causes of delay in labour several are
enumerated which are nowadays little accounted of or not
considered at all, while others are omitted which are of
importance. Few, for instance, will agree with the statement
that the " byrth of the man is generally easier then the byrth
of the female." Some of the causes are curiously set forth,
such as, if the mother be " too spare or leane, or that she never
had chylde before, or that she be over timorious and fearefull,
dyvers, waywarde, or such one that wyll not be ruled, removy-
ing her selfe from one place to another." The old belief in
the birth of the child by its own efforts appears in such
statements as : " yf the childe be so faynt, weake and tender,
that it cannot tourne it selfe or doth it very slowly ; " " also if
the childe be dead in the mothers belly, it is a very perellous
thing, for so much as it cannot be easely turned, neither can it
welde or helpe it self to come forth, or if the chyld be sicke or
weakned so that it cannot for feblenes helpe it self." Then,
various signs are enumerated to help the midwife to tell in
what cases the unborn infant is weak or sick, such as if the
pregnant woman has been " sore lasked," * if she have had
" dayly and unwontly her flowres," if " strayght after one moneth
upon the conceptyon her brestes yelde any milke." Causes of
delay due to teratological states were not unknown to the writer,
for he says that there will be difficulty if that with which the
woman laboureth " be a monster, as for example, yf it hath but
one bodye and two heades, as appereth in the XVII. of
the birth figures such as of late was sene in the dominion of
Werdenbergh." 2 Faults in the "secondine or latter birth"
1 Lasked, purged.
2 Werdenbergh, a town in Switzerland on the Rhine, in the Canton
of St Gall. The monstrosity referred to appears as fig. x., near the end
of this article.
268 THE "BYKTH OF MAKKYKDE,"
(membranes), such as firmness or slenderness are also named,
and the delay due to loss of humidities from early rupture is
referred to. "And farther if the woman have used to eate
commonly suche meate or fruytes, which do exiccate or drye,
and constrayne or bynde, as Medlars, Chestenuts, and al sowre
fruites, as Crabbes, Chokeperes,1 Quinces and suche other, with
over muche use of Vergeus,2 and such lyke sowre sauces, with
Eise, Mill,3 and many other thynges, all thys shall greatly hynder
the byrth." " Also," the writer continues, " the use of colde
bathes after the fyrst moneth folowing the conception, or to
bathe in such water where Alome is, Iron, or Salt, or anye
suche thynges whiche do coarcte and constrayne, or yf she have
bene often tymes heavye and mourninge, or ill at ease, or yf she
have bene kepte over hungry and thursty, or have used over
much watche and walkinge, eyther yf she used a lyttle before
her labour things of great odour, smel, or savour, for suche
thynges (in manye mens opinions) attract and drawe upward
the Mother or Matrix ; the which is great hinderaunce to the
byrth."
The chapter closes with an enumeration of the tokens of an
easy labour. "Nowe sygnes and tokens of an expedite and
easie delyveraunce, be suche as be contrarye to all those that
have ben rehearsed before. As for example, when the woman
hath bene wonte in tymes passed, easely to be delyvered, and
that in her labour she feele but little thronge or dolour, or
though she have great paynes, yet they remayne not still in the
upper partes, but descend alwaies downewardes to the nether
partes or bottome of the belly. And to be short, in all payne-
full and troublesome labours these signes betoken and signifie
good spede and lucke in the labour : unquietnes, much styringe
1 Choke-pear, any "rough, harsh, and unpalatable variety of the
pear, used for perry," a sort of crab-pear.
2 Vergeus, or verjuice, a liquor expressed from crab-apple, sour grapes,
etc.
3 Mill, millet.
BY DR J. W. BALLANTYNE. 269
of the chylde in the Mothers bellye, all the thronges and
paynes tomblynge in the forepart of the bottome of the
belly, the woman stronge and mightie of nature, such as can
wel and strongly helpe her self to the deliveraunce of the byrth.
And agayne, evyl signes be those, when she sweteth colde
sweate, and that her pulces beate and labour over sore, and that
she her self in the labouring faint and sowne, these bee unluckie
and mortall signes."
The third chapter of this Book is, in some respects, the
most important and the most interesting of the whole work, for
it deals with " howe a woman with childe shal use her selfe,
and what remedies be for them that have harde labour." If
there should be any disease, swelling, or apostumation (abscess)
about the uterus, vulva, or bladder (such as stone or strangury),
then " in these cases it behoveth such thynges to be loked unto
and cured before the time of laboure commeth, by the advise of
some expert Surgion." Her diet x before labour will be different
from that during labour. If there be constipation, she must
use "suche thinges, the whiche may lenifie, mollifie, dissolve,
and lose the belly : as apples fried with suger taken fastynge in
the mornynge, and after that a draught of pure wyne alone,
or elles tempred with the juyce of swete and very rype apples.
Also to eate figges in the mornynge fasting, and at nyght,
looseth 'well the bellye. If these profite not, Cassia fistula
taken iii. or iv. drams one halfe hour before diner, shal loose
the belly without parel." The woman also must refrain from
taking constipating things (" hard egges," etc.), and it may be
necessary for her to get a clyster, " but it must be very gentle
and easye." An easy and temperate purgation (as by mercury)
may be needed, "or elles a suppositar tempered with sope,
larde, or the yolke of egges." If she be faint or sickly just
before her labour, "then must ye comfort her with good
1 Diet here means course of living and not simply the food or drink
taken.
270 THE "BYRTH OF MANKYNDE,"
comfortable meate, drinke, holsome and noble electuaries."
Various ointments and baths are to be used before labour:
" Annointmentes wherewith ye may sople the privie place,
be these. Hennes grese, Duckes grese, Goose grese, also
oyle Olife, Linsede oyl, or oyl of Fenegreke, or the visco-
site of holyoks." She is to bathe in water in which have been
seethed "Malowes, Holyoke, Camomel, Mercury, Maiden-
haire, Lyneseede, Fenegreke seede, and such other thynges
which have vertue to mollifie and sople." If she be not able to
take such baths, she must sponge herself with the water and
apply ointments locally. Sweet fumes also are useful: "it
shalbe also very profitable for her, to suffume the nether places
with muske, Ambre, Gallia, Muscata, which put on embres,
yelde a goody savoure, by the whiche the neather places open
theymselfe, and drawe downwarde." She must also " exercyse
the bodye in doing some thinge, styring, moving, goynge, or
standinge, more then otherwise she was wont to doe."
Hints are given as to what must be done when labour pains
come on. " To withstand, defend, and to put away so neare as
mai be the instant and present dolours. And as touchinge
this poynt, it shalbe verye profytable for her, for the space of
an houre to syt styll, then (rysynge agayne) to goe up and
downe a payre of stayres, crying or reaching so loude as she
can, so to styre her selfe."
Here follows the oft-quoted passage about the "womans
stoole " or " obstetric chair " which is represented in the Birth
Figures. "Nowe when the woman perceaveth the Matrix or
Mother to ware laxe or loose, and to be dissolved, and that the
humours yssue foorth in great plentie, then shall it be mete
for her to sit downe leaninge backwarde in maner upright.
For the which purpose in some regions (as in Fraunce and
Germany) the Midwyfes have stoles for the nonce, whiche
beynge but lowe, and not hye from the grounde, be made so
compasse wyse and cave or holowe in the middes, that that
BY DR J. W. BALLANTYNE. 271
mai be receaved from underneth which is looked for, and the
backe of the stole leaning backeward, receaveth the, back of
the woman, the fashion of the which stole, is set in the begin-
ning of the birth figures hereafter. And when the tyme of
laboure is come, in the same stoole ought to be put many
clothes or cloutes in the back of it, the which the Midwife
may remove from one syde to another accordinge as necessitie
shall require. The Midwyfe her selfe shall syt before the
labourynge woman, and shall diligentlye observe and wayte,
howe much, and after what meanes the chylde styreth it selfe,
also shall with her handes fyrste annoynted with the oyle of
Almondes, or the oyle of whyte Lyllies, rule and dyrecte every
thyng as shall seme beste. Also the mydwife muste enstructe
and comfort the partie, not only refreshing her with good
meate and drink, but also with swete woordes, gevynge her
good hope of a spedefull delyveraunce, encouraginge and
enstomakinge her to pacyence and tolleraunce, byddynge her
to holde in her breath so much as she may, also strekinge
gentilly with her handes her bellye above the Navell, for
that helpeth to depresse the birth downewarde."
If the patient, however, be fat, the writer recommends
that she " lye grovelynge," and if necessity require it " let not
the midwife bee afrayde ne ashamed to handle the places, and
to relax and loose the straites (for so muche as shal lye in
her), for that shal helpe wel to the more expedite and quicke
labour." She is warned, however, against interfering too soon
" before the byrth come f orwarde," and she ought not to allow
the patient to expend her strength before the proper time.
When the bag of membranes appears, " then maye ye knowe
that the labour is at hand." If the bag do not burst of its own
accord, "it shalbe the Mydwyfes part and office, with the
nayles easely and gen telly e to breake and rent it, or yf that
may not conveniently be done, then rayse up betwene your
fyngers a peece of it, and cut it with a payre of shieres, or a
272 THE "BYRTH OF MANKYNDE,"
sharpe knyfe, but so that ye hurt not the byrth with the cut."
If the membranes have ruptured or been ruptured too early,
a dry labour results requiring the application of "oyle of
why te Lyllyes or some of the greses spoken of before " to the
parts; "but chiefely in these difficulties should profite the
whyte of an egge together with the yolke powred into that
same place : which shoulde cause it to be most slyppery and
slydynge, and supplye the roome of the naturall humidities
spent before."
The birth of a child with a large head or of twins is to be
assisted by the midwife, who is to " helpe all that she maye,
with her hande fyrste annoynted with some oyle openying and
enlargyng the waye that the issue maye be the freer."
So far the writer has been dealing with the " natural byrth
when that first proceadeth the head," as is represented in the
first of the Birth Figures. He now describes in turn the various
ways in which the infant or infants may present, and in what
manner the midwife is to treat them. In the second of the
Birth Figures a child is represented coming feet first (the
attitude of the foetus is wrongly represented, as it is indeed in
most of the figures), and in such circumstances the midwife is
apparently directed to perform cephalic version ! Here, at any
rate, are the directions : " Sometime it chaunced the child to
come the legges and both armes and handes downwarde, close
to the sydes fyrst foorth, as appeareth in the seconde of the
byrth figures. In this case the Mydwyf e must do all her payne
with tender handlynge and annoyntyng to receave foorth the
chylde, the legges. beynge styll close together and the handes
lykewyse remaynynge as appeareth in the seconde figure.
Howbeit, it were farre better (yf it may be done by anye
possible wayes or meanes) that the Mydwyfe shoulde tourne
these legges commyng fyrst foorth, upwardes agayne by the
bellywarde, so that the head myght descende downewarde by
the backe parte of the wombe : for then naturally agayne and
BY DR J. W. BALLANTYNE. 273
without peryl might it proceade and come forth as the
fyrste."
In the third of the Birth Figures the foetus is represented
as coming by the feet with the arms displaced upward along-
side of the head. "This is the perylloust maner of byrth" ;
and the direction is that the midwife must do what she may
" to turne the byrth (yf it may be possible) to the first figure,"
but no directions are given as to the way in which this is to be
done. If she cannot do this, she is directed to convert it into
the second figure by bringing down the hands ; and " if this
also wyll not bee, then receave the feete as they come foorth,
and bynde them with some fayre linnen cloth, and so tenderly
and very softly lose out the byrth tyll all be come foorth,
and this is very jeoperdous labour." When one foot only
presents {Birth Figure IY.) version by the postural method (" the
labouring woman's head to be the lower part of her body")
is to be followed ; but if it do not succeed, the midwife is to
bring down the other foot. The fifth Birth Figure represents,
rather crudely, a transverse presentation ; the sole direction
for its management is : " then must the Mydwyfe do so, that it
may be returned to his naturall fashion, and so to come foorth."
The sixth and seventh cases call for no special comment. The
eighth Birth Figure shows descent of one of the arms alongside
of the head ; under these circumstances the midwife is told to
thrust the birth in again, and if this fail she is to try postural
treatment ; the same procedure is to be adopted in the ninth
mode of presentation when both hands come down. The
directions for the management of a breech case {Birth Figure X.)
are surprising: "Then must the Mydwyfe with her handes
returne it agayne, untyll such tyme that the birth be turned,
the legges and feete forwarde." A shoulder presentation is
shown in Birth Figure XII. (described erroneously in the
text as XI.), and the direction is, " then must ye fayre and
softly thrust it back agayne by the shulders, tyll suchetyme as
S
274 THE " BYRTH OF MANKYNDE/'
the heade come forwarde." Twin cases are shown in the Birth
Figures XIV., XV., and XVI. ; in the first are two heads, in
the second two breeches, and the third is a head and a breech
presentation. In the description appended to the last-named
mode of labour there is the suggestion that the possibility of
head-locking was not unknown to the writer.
On the whole, it must be admitted that the management of
labour as set forth in this chapter falls far behind modern
practice, not to say theory. The notions regarding the attitude
of the foetus in utero were erroneous, the distinctions between
the various presentations were incomplete {e.g., face cases are
not figured or named), and the management not infrequently
consisted in interfering in the cases which we should now leave
alone and in using ointments and posture under circumstances
in which more radical methods would now be adopted. One
cannot help wondering also how the midwives carried out the
. instructions given to them ; certainly they were not burdened
with details.
The fourth chapter (wrongly described as the fifth in this
edition of 1650) deals with " the remedies and medicines by the
which the labour may be made more tollerable, easy, and
without great payne." The posture of the patient, the tempera-
ture of the lying-in room, the provocation of sneezing (" and
that eyther with the powder of Meborus1 or els of pepper"),
and the use of ointments are all referred to. Of the oils,
ointments, perfumes, washes, drinks, pills, and plasters mentioned
in this chapter, we need mention two only. Here is a perfume :
" Take yelowe brymstone, Myrre, Mader, Galbanum, Oppopona-
cum, of eche lyke much, and tempre all those together, makynge
of them pylles, and with those also ye maye make fume, to be
receaved underneath." The chapter closes with the prescrip-
tion of "a plaster to provoke the birth." Here it is: "Take
1 Eleborus, Hellebore, White Hellebore ( Veratrum album), was used
as a sternutatory.
BY DR J. W. BALLANTYNE. 275
wylde Gowarde,1 and seeth it in water, in the same water
temper Myrre, the juyce of Rue, and Barlye meale so much as
shalbe sufficient, stampe these thynges together, and make it
plasterwyse, then laye it to the womans bellye betwene the
Navyll and the nether parte. This plaster shall helpe mar-
veylously."
Chapter V. is concerned with "howe the secondine or
seconde byrth shalbe forced to issue foorth, if it come not freely
of his owne kynde." Various causes of the non-expulsion of
the placenta and membranes are enumerated, such as lack
of strength from prolonged labour, " entanglement " of the
secondines within the uterus, and swelling of the parts. The
dangers of placental retention are also named, and include
" suffocation and chokinge of the Matrix " and putrefaction of
the after-birth. " The seconde birth retayned and kept within
will soone putrifie and rot : whereof wyll ensue yll noysom and
pestiferous vapoures ascendinge to the heart, the braynes and
the midriffe, through the which meanes the woman shalbe
short wynded, faynte harted, often soundinge and lyinge with-
out any maner of movynge or styrringe in the pulces : yea, and
many tymes is playnely suffocated, strangled and dead of it."
The remedies proposed for non-expulsion of the placenta were
founded to some extent upon the causal conditions so far as
these were understood. If weakness from long labour were
the cause, then must the "labourer" be "recomforted and
strengthed with good comfortable meates and drinkes, which
maye enhart her, as broath made of the yolcke of egges, or with
good olde wine, and good fat and tidie fleshe, or Byrdes, Hennes
fleshe, Capons, Partrige, Pigins and such like." If the cause
were contraction of the passages, then oils and ointments
are recommended to " make the waye slypper, sople, and easy
for it to proceade." Perfumes, also, and vapours are said to be
efficacious. "But if the retencion of the secondine come by
1 Gowarde, Wild Gourd, Colocynth.
276 THE "BYRTH OF MANKYNDE,"
reason that it is entangled or fastened in some place of the
Matrix, so that it wyll not resolve ne loose ; then make a fume
underneath of Brimstone, Ivie leaves, and Cresses, or elles of
Cresses fygges." There are some curious restrictions, of which
the following is an instance: "Also of all odoriferous and
sweete smellinge thinges, as Ambre, Muske, Frankencense,
Gallia Miiscata, and confection, neare the which savoures and
perfumes put on the embers muste be so closely receaved
underneth, that no part of the smell do ascende to the nose
of the woman. For to the nose shoulde the savoure of nothynge
come, but onely of suche thinges, the which stinke or have
abhominable smell, as Asafetida, Castorium, mans hayre or
womens hayre burnt, Pecockes fethers burnt." " Item let her
be provoked to sneese with the powder of Eleborus or Pepper
put in the nose, holdinge her mouth and nose so close as
maye be."
The following directions for the removal of the after-birth
are interesting: "And yf it bee so that any parte of the
secondine do appeare, let the Mydwife receave it tenderly,
losynge it out fayre and softly, least it breake, and if ye doubt
that it wil breake, then let the Mydwife tye that parte of the
whiche she hath handfast to the womans legge or fote, not
very strayght, least it breake, nether very lax, least it slip in
agayne, and then cause her to sneese. Nowe yf the secondine
tarye or stycke, so that it come not quickly forewarde, then
loose it a lyttle and a lyttle very tenderly, wrethinge it from
one syde to another, tyll such time as it be gotten out, but ever
beware of violent and hasty movynge of it, leaste that with
the seconde byrth ye remove the Matrix also." The danger of
inversion of the uterus is doubtless alluded to in this last
passage. The chapter closes with directions for a fumigation
and a plaster, and with the following somewhat despairing
instruction : " If for al this the secondine come not forewarde,
then leave it, and use no more medicines ne remedyes to that
BY DR J. W. BALLANTYNE. 277
purpose, but let it alone, for within fewe days it wyll putrifie
and corrupt, and dissolve into a watery substaunce, thick like
bryne, or other fex myxed with water, and so yssue foorth.
Howbeit in the meane whyle it wyll put the woman to great
paine in the head, in the heart, and in the stomacke, as we
touched before."
The sixth chapter is a long one, dealing with such important
matters as "howe many thinges chaunce to the women after
theyr laboure, and how to avoyde, defende, or to remedye the
same." Among the "many thinges" are "the fever or ague
or swelling, or inflation of the bodye, other tumblynge in the
belly, or elles commotion or settelinge out of order of the
Mother or Matrix," and the cause of these is sometimes " lacke
of due and sufficient purgation and clensynge of the flowres
after the byrth, or els contrarywyse over muche flowinge of
the same, whiche sore doth weaken the woman, also the great
labour and styrrynge of the Matrix in the byrth."
The " ague " we may shrewdly suspect was septic poisoning,
" for that commeth of like cause by retention of the flowres."
The patient is then to " drinke water in the whiche is decocte
Barley beaten, or Cicer1 and Barley together, or water in
whiche be sodden Tamarindi, or whaye of mylke, and let her
eate Cullis2 made of a Cocke, and sweete Pomegarnates, for
these thynges do provoke the flowres," etc. Various remedies,
resembling those already referred to, are to be given in such
conditions as swelling of the body, "frettinge and knawynge
of the guttes," " paine in the privie partes," " outragious flux of
flowres," "coming forth of the fundament gut," and the like.
It is unnecessary to describe in detail the curious plans
adopted and mixtures administered in these cases, one instance
must serve for all: "To stynte and restrayne the outragious
fluxe of flowres, it shalbe verye good to binde the amies
1 Cicer, a chick-pea.
2 Cullis, a strong broth, a beef -tea.
278 THE "BYKTH OF MANKYNDE,"
strayght and strongly, and not the feete or handes, as some
unwyse men doe teache, and then to set a ventose boxe, or
cupping glasse with fyre (which is called borying) under the
brestes without anye scarification." Here is one of the
plasters: "Take of the bloud stone called Emathites, Bole
armeniacke of eche halfe an ounce, Sanguis draconis, Licium,
of eche twoo drammes, Karabe, otherwye named Ambre, the
cuppes of Acornes, Cipres tree nuttes, flowres of Pomegranade,
of eche one dram, of the scales of Iron one dram and a halfe,
Turpintine and Pitch lyke quantitie, or so much as shalbe
sufficient to make a softe and somewhat liquid plaster."
The next chapter (the seventh) deals with " aborcementes
or untymelye byrthes, and the causes of it, and by what
remedies it may be defended, holpen, and eased." Many
curious causes are enumerated, among which is "a disease
called Tenasmus, the which is when hath ever greate desyre
and luste to the stool, and yet can do nothynge." Other
causes are coughing, bleeding at the nose, "to be let bloud,"
strong purgation, hunger, cold, heat, etc. "Therefore ought
women with chylde to eschewe much bathyng or going to
the hotte houses in theyr teming" (teeming). "Item, the
intemperancie and mutation of the ayre and weather may be
cause of aborcement," and after this statement there follows
an interesting paragraph on meteorology in its relation to
health, as it was then understood. "Dancing and leaping"
are also named as possible causes, and so are " sodayne anger,
feare, dread, sorowe, or some sodaine and unloked for joy."
To the modern reader the signs of abortion enumerated by
the writer of the Byrth of Manhynde will appear most astonish-
ing and unconvincing ; among them he will find " a great ache
in the inner part of the eies toward the braynes," redness of
the face, " ventositie or wynde runnynge from one syde of the
bodye to the other." kt the same time there is a reference,
but a very brief one, to the really important sign of "greate
BY DR J. W. BALLANTYNE. 279
paynes and dolours of the Matrix." The means of diagnosis
given are hardly such as to justify the author's confident
assertion : " thus have I sufficently declared evident sygnes,
whereby may be provyded and foreseene the aborcement before
it come." The methods of treatment are those which we now
have come to look for from our author, — baths, fumigations,
plasters, ointments, odours, and such like; but he gives the
midwife one good piece of advice: "Howbeit, in all thys
matter, let not to make some expert Phisition of youre counsaile,
yf ye may have suche one : for because that manye such thinges
come, and not all by one way or meane."
The eighth chapter (wrongly named the ninth in the edition
of 1560) is concerned with "dead byrthes, and by what sygnes
or tokens it maye be knowen, and by what meanes it may also
be expelled." The signs are twelve in number ; but they are
not very convincing, as may be gathered when it is noted that
the twelfth sign is, if the mother's "handes put into very warme
water, and then laycle on the belly, and the childe steare not."
There is evidence of sound knowledge, however, in the statement
that " of all these sygnes nowe, the more that come togeather of
theym at one tyme and in one person, the surer maye ye be
that the byrth is dead."
The prognosis, grave or favourable, in cases of dead-birth
labours is set forth : " Whether the Mother shalbe in parell
or no, by these thinges shall ye knowe. If the woman beynge
in the laboure sowne or feare as though she were in a transe :
yf her remembraunce fayle her, and she were feble and scante
able to moue or styre herselfe, yf she (called with a loud voyce)
canne aunswere nothinge at all, or elles verye lyttle, and that
verye softely, as though her voyce began to fayle her : if she
be invaded or taken among in the labouring with convulsion or
shrinkelynge together : if she refuse or cannot brooke meat : yf
her pulces beat every faste, the which signes when ye se in the
woman labouringe, it is an evident token that she shal not lyve
280 THE "BYRTH OF MANKYNDE,"
longe after her delyveraunce, wherefore commit the cure of her
to the handes of almyghtie God."
The treatment consists in getting ride of the " dead burthen "
either by " medicines expulsy ve " or else by certain instruments
made " for the nonce." Here, again, we find described a long
list of fumigations, containing such things as the hoof or dung
of an ass, the skin of an adder, "hawkes' dung" or "oxe gall,"
of suppositories or pessaries, of drinks (" yf the woman drynke
the mylke of another woman, it will styre and expell the
byrthe "), and of plasters. " But yf all these medicines profyt
not, then must be used more severe and harde remedyes, with
instrumentes : as hokes, tounges, and suche other thinges made
for the nonce." From the wording of the directions it is
evidently intended that the midwife herself shall fix the hooks
into the eyes, or mouth, or shoulders, or ribs of the dead foetus
and make traction, other women keeping the patient down.
Arms and legs are to be cut off, if need be, and the head is to
be opened with a sharp penknife if it be much swollen. Both
the head and trunk may have to be broken up into pieces with
" such instrumentes as the Chirurgions have readye and neces-
sarye for suche purposes."
The last paragraph of this chapter must be quoted entire :
" But contrary to all this, yf it chaunce that the woman in her
labour dye, and the chylde having lyf e in it : then shal it be
meete to kepe open the womans mouth, and also the nether
places ; so that the chylde may by that meanes both receave
and also expell ayre and breath, which otherwyse myght be
stopped, to the destruction of the chylde. And then to turne
her on the lefte syde, and there to cut her open, and so to take
out the chylde. They that be borne after this fashion are called
Cesares, for because they be cutte out of theyr mothers belly :
whereupon also the noble Komayne Cesar the fyrste toke his
name." Assuredly the directions given here for a post-mortem
Cesarean section are not too explicit !
BY DR J. W. BALLANTYNE. 281
Chapter IX. (by error called Chapter X. in the Kaynalde
editions) has no representative in the 1540 edition or in
Kosslin's De Partu Hominis, and we must, therefore, ascribe it
to Kaynalde. It contains a list of medicines, ointments, and
plasters (" suche as hath ben wel experimented and practysed "),
to be used to quicken delivery and to expel the after-birth. The
reader is, by this time, able to foretell pretty accurately what
kind of drugs will be in these medicines, and I need only refer
to certain " trochiskes " upon which the writer evidently places
much reliance. " Item, of Saffron dried by the fyre tyl it be
blackyshe, of Cassia lignea, fine Keubarbe, Savine dryed,
Myrreh, of eche of these seven scruples, of pure muske, xvi.
graynes, every of these simples exquisitely by them selves
powdred, and then perfectlye myxed in one, with vi. or vii.
droppes of Malvesey, temper the whole mase into lyttle
roundels or trochiskes, eche waying a dram. And in tyme of
neede at the womans labour, geve her hardly the wayght of vi.
d. of these trochiskes beaten into fine powder, with foure
sponefulles of Isope water, and other foure of good wine secke."
The chapter closes with a paragraph (to which I have referred
in my previous article as the " Bucklersbery paragraph") telling
where the " trochiskes " are to be obtained.
Such are the contents of the Second Book as they appear in
the 1560 edition. There are slight verbal differences in some
of the other editions, and these specially affect the " Bucklersbery
paragraph." More distinct variations separate the 1540 or
Jonas editions from that of 1560 and from the rest. The
whole of the ninth chapter (erroneously called the tenth) is
absent from the 1540 edition ; there is a difference in the
wording of the commendation of the "plaster to provoke the
birth," Jonas being less certain about its efficacy than Kaynalde,
and throughout the whole book Jonas is more in the habit of
introducing such phrases as "Avicenna saith" or "Hippocrates
writeth " than Kaynalde (e.g. in Chapter VIIL). The differences
282 THE "BYRTH OF MANKYNDE,"
are simply due to the fact that Jonas translated Kosslin's book
literally, whereas Eaynalde gave a more free rendering and
supplemented the work here and there. For this reason, also,
it comes about that the Second Book of the Eaynalde editions is
part of the First Book of the Jonas edition, for it really
represents Chapters II. to IX. of Kosslin's De Partu Hominis.
Jonas's First Book corresponds to Chapters I. to XL of Kosslin.
The "Byrthe Fygures."
The "Byrthe Fygures," including the "Woman's Stoole,"
belong to the Second Book of the 1560 and of the other
Eaynalde editions. They are all taken from Kosslin's De
Partu Hominis, but they are not placed in the same order.
Further, there is one in Kosslin's book which does not appear in
the 1560 edition (or, so far as I know, in any of the Kaynalde
editions); this has been reproduced in Fig. V. It will be
noted that in some respects it more nearly represents the true
attitude of the foetus in utero than any of the others. I have
reproduced five of the Kosslin figures (including the " Stoole ")
which have their representatives in the Kaynalde editions
(Figs. YI.-X.), so that the reader may compare them with the
same pictures as they appear in the English translation (see my
previous article, Plates VIII., IX., X., and XL). I have already
(loo. cit.) referred to the great interest which the " Byrth Fygures "
of the Byrth of Manhynde have excited as being the earliest, or
almost the earliest, specimens of English copperplates.
The Third Book.
The Third Book of the 1560 edition of the Byrth of Man-
kynde consists of three chapters, the third being a very long
one. It is devoted to the care of the new-born infant, and to
its " dy verse diseases and inf yrmities " : the first chapter speaks
BY DR J. W. BALLANTYNE. 283
of the umbilical cord and its management, the second of the
nurse and her milk, and the third of the maladies of infants
and the remedies required for them. "Then after that the
Infant is once come to lyght, by and by the Navyll muste be
cut three fyngers breadth from the belly, and so knit up, and
let be strued on the head of that remayneth, of the powder of
Bole armeniacke, and Sanguis draconis, Sarcocolla, Myrrhe, and
Cummin, of eche lyke muche beaten to pouder, then upon that
bynd a peece of woll, dypped in oyle Olive, that the powder
fall not of. Some use fyrst to knyt the Navyl, and after to cut
it so much, as is before rehearsed." The writer mentions the
belief that the length of the stump of the cord will determine
the length of the " chyldes tonge," if it be a man-child. He
also refers to Avicenna's statement that the wrinkles on the
cord betoken the number of future pregnancies the patient is to
have and the intervals of time (long or short) between them ;
" but these sayinges be nether in the G-ospell of the day, ne of
the night."
The child's body is to be rubbed with oil of acorns. " After
this annoyntyng, washe the Infante with warme water, and
with your fynger (the nayle beyng pared) open the chyldes
nosethrilles, and purge them of the fylthiness." After the fall
of the cord (" whiche commonlye chaunceth after the thyrde or
fourth daye") the cicatrix is to be dusted with "ashes of a
Calfes hove burnte, or of Snayle shelles, or of the powder of
lead, called red lead, tempered with wyne." The proper
swaddling of the child is then described, so that its limbs may
grow straight ("as it is in yonge and tender impes, plantes,
and twygges ") ; the eyes should be frequently washed, and it
should sleep in its cradle in such a place that neither the
beames of the Sunne by day, neither of the Moone by nyght
come on the Infant." It is to be washed two or three times a
day; and, after that, to put a drop or two of water into its
nostrils is " very good for the eye syght."
284 THE " BYRTH OF MANKYNDE "
" It shalbe beste that the mother give her chylde sucke her
selfe, for the mothers mylke is more convenient and agreable to
the infant, than any other womans, and more doth it nouryshe
it, for because that in the mothers belly it was wont to the same,
and fed with it, and therefore also it doth more desyrouslye
covet the same, as that with the which it is best acquainted."
Apparently the nursings are not to be frequent : " As Avicenna
writeth it shalbe sufficient to give sucke twyse or thryse in a
daye." If the mother be unable to suckle her child, then
a " holsome Nourse " is to be sought out ; five or six essential
qualities are enumerated which she must possess, and a method
of testing the milk upon the thumb nail is described. There
is a long list of remedies which are said to increase the quantity
of the milk. Two instances must serve : " Item, to eate shepes
brestes, and the mylke of them is good " ; " Item, take two
drams of Crystall beaten into fyne powder, and devyde that in
f oure equal partes : one of these partes geve unto the Nourse,
the space of foure dayes to drynke, with broth made eyther of
Cicer,1 or elles of peason." 2 The child is not to be put to the
mother's breast for a day or two after birth, " because that the
creme (as they cal it) straight after the byrth, the first day in
al women doeth thicken and congile." This, it need hardly be
said, is not the rule of procedure at the present time. Weaning
should take place at the end of the year, and it is not to be
carried out suddenly but gradually; the infant is not to be
given "lyttle pylles of bread and sugar to eate" until it be
able to " eate all maner of meate."
The third chapter of this book is taken up, as has been said,
with the diseases of infants and their treatment. It is of interest
rather to the pediatric physician than to the obstetrician ; but
I may enumerate some of the subjects dealt with : " loosenesse
of the bellye, cough and distillation,3 short winde, wheales on
1 Cicer, chick-pea. 2 Peason, pease.
3 Distillation, a catarrh or defluxion of rheum.
BY DR J. W. B ALLAN TYNE. 285
the tounge, apostumation and runninge of the eares, bolnynge1
of the eyes, often sneesinge, whelkes in the body, swelling of
the coddes,2 unslepinesse, yeringe or the hyckate,3 terrible
dreames, wormes in the belly, the fallynge syckenes, the palsey,
and gogle eyes 4 or loking squint." It is unnecessary to quote
the means recommended for the treatment of these various
maladies, but the following prescription for the falling
sickness (epilepsy) may be given by way of sample: "Item,
to hange Viscum quersinum,5 which is gathered in Marche
the moone decreasynge, about the Chyldes necke, is very
good."
The Third Book as it appears in the 1560 edition differs
little from what it is in the other Eaynalde issues, earlier or
later. I have found a few verbal differences between it and the
1552 edition (e.g., in the paragraph on " Unsleppynesse "), and
in the 1654 edition there is a new chapter (placed quite at the
end of the work) amplifying what has been said about the
nursing of children and " how' to choose a good nurse." The
1540 edition differs more markedly: the chapter on "unsleepi-
ness" is shorter, that on swelling of the coddes is not the
same; there are two additional short paragraphs (the one
" against the mother," and the other of short breath, hoarseness,
or whistling in the throat), and there is an additional sentence
on infantile constipation.
The Third Book of the Eaynalde editions corresponds to
Chapters X. and XI. of the First Book and to the whole of the
Second Book of the 1540 or Jonas edition. It forms, also, the
tenth, eleventh, and twelfth chapters of Be Tartu Hominis,
from p. 61 to the end (in the edition of 1538).
1 Bolnynge, swelling or a tumour.
2 Coddes, testicles.
3 Hyckate or yexing, the hiccup.
4 Gogle eyes, staring eyes or squint eyes.
,r> Viscum quersinum, mistletoe of the oak.
286 THE "BYRTH OF MANKYNDE,'
The Fourth Book.
The Fourth Book of the 1560 as well as of the other
Kaynalde editions consists of six chapters ; these are not found
in Kosslin's De Partu Hominis, but five of them are present in
the 1540 or Jonas edition of the Byrth of Mankynde, so that
only one (the sixth) chapter is peculiar to the Baynalde
editions. The Fourth Book of the 1545 and of all later
editions corresponds to the Third Book of the 1540 or first
impression.
An idea of the subjects dealt with in the Fourth Book can
best be obtained from the short summary contained in the
first chapter. I quote (in this instance) from the 1552 edition :
" Here in this fourth Boke (by ye leave of God) shal brefely be
declared soch thinges which may farther or hinder the con-
ception of man, whych as it may be by dyvers meanes letted
and hyndered, so also by many other wayes it may be farthered
and amended. Also to knowe by certayne sygnes and tokens
whether the woman be conceaved or no, and whether the con-
ception be male or female, and finally certayne remedies and
medicines to farther and help conception : and there after we
wyll (accordynge to our promyse in the prologue) set forth
certayne bellyfying receptes, and so make an ende of this hole
treatyse."
The second chapter gives the author's views as to the
necessary conditions for the growing of corn between which
and human generation he draws a parallel : " Ther be in al maner
of generation thre principal partes concurrent to the same : ye
sower, the sede so wen, and the receptacle or place receaving
and contayninge the seede." The third chapter applies this
principle to the consideration of the causes of sterility, and
enumerates faults in the mother receiving the seed, faults in
the sower, and faults in the seed itself. The mother's womb
BY DR J. W. BALLANTYNE. 287
is fancifully compared to the ground ; it may be too hot, too
cold, too moist, or too dense. The following paragraph may be
quoted to show how the author persuades himself that coldness
of the matrix is a cause of sterility : " Tor yf corne be sowen in
over cold places, soch as be in the partes of a countrey, called
Sithia, and in certayne places of Almayne, or in soch places
where is contynual snow or frost, or wher the sunne doth not
shyne: in these places the sede or grayn sowen, wyl never
come to profe, nor fructyfy, but through the vehement coldnesse
of the place in the which it is conceaved, the lyfe and quickenes
of the grayne is utterlye destroyed and adnihilat." The man's
seed also may be defective as to heat, cold, thickness, etc.
Even more fanciful is the fourth chapter, which pretends to
give ways of finding out whether sterility is due to defect in
the woman or the man. "Let eche of theim take of wheate
and barleye cornes, and of beanes of ech vii., the which they
shal sufFre to be steped in theyre severall uryne : the space of
xxiiii. hourses : then take ii. pottes, soch as they set gylyflowres
in : fyl them wyth good earth : and in the one let be set the
wheat, barlye, and beanes, styped (steeped) in the mans water,
and in the other the wheat, barly, and beanes styped in the
womans water: and everye morninge the space of viii. or x.
dayes, let eche of them with theyr proper urine water the sayd
sedes sowen in the foresayd pottes and mark whose pot doth
prove, and the sedes therein contayned doth grow, in ye partye
is not the lack of conception, and se yf ther come no other
water or rayne on the pottes." This marvellous test ends with
the wise remark, "but trust not moch this farfet1 experiment."
Other tokens are given, taken from the works of Hippocrates
(which are often quoted in this Book), but the writer warns the
reader that "these tokens, although they have a certain reason
and apparence, yet be they not alwayes unfallyble, but onely
lycklye" The signs of pregnancy are described (menstrual
1 Farfet, far-fetched.
288 THE "BYKTH OF MANKYNDE,"
suppression, changes in the breasts, " longings," and thickness
of the urine), and directions are given to enable the midwife to
tell whether the unborn child is male or female.
The fifth chapter contains various prescriptions supposed to
be efficacious in curing sterility, but they call for little comment
and no commendation, being founded upon the etiological
theory of lack of heat or cold or moisture in the woman or in
her uterus.
The sixth and last chapter of the Fourth Book may be called
the " cosmetic " one, for it deals with what the writer (Eaynalde)
calls " dy vers bellyf ying " medicines and remedies. It is pro-
posed to show how certain blemishes (" as it were weedes of the
body") are to be removed, such as "dandraffe" of the head,
" hayre in places where it is unsemelye," " frekens or other
spottes in the face," warts, and "pymples." There are also
instructions how to keep and preserve the teeth clean, and how
to prevent " stynckynge breath " and " ranke savour of the
armeholes." I need only quote the last paragraph: "Item,
auctors do wryte the ye rootes of artichauts (ye pithe pyked
oute) soden in whyte wyne and so dronke, doth dense the
stenche of the arme holes and other partes of the body by the
wyne : for (as Gallen also doeth testyfye) he provoketh copy
and plenty of stinkynge and unsavery uryne, from all partes of
the body, the whych propertye it hath by specyall gyft and not
only by his hote qualyte. And thus here I make an ende of
thys fourth and last boke."
The sixth chapter is wanting in the Jonas edition of 1540,
but is to be found in all the Eaynalde editions from that of
1545 onwards.
No part of the Fourth Book is to be found in either of the
editions of Eosslin's Be Partu Hominis, and we must conclude
that Chapters I. to V. were written by Jonas, Eaynalde adding
the sixth. Both Eaynalde and Jonas seem to have gone to
Hippocrates for their facts (if facts they can be called), or! to
BY DR J. W. BALLANTYNE. 289
some work which quotes Hippocrates. The latter is the more
probable explanation of the source of the Fourth Book.
Ehodion's "De Partu Hominis."
As we have seen, Jonas translated Eosslin's or Ehodion's
De Partu Hominis into English, adding a few chapters thereto,
and Eaynalde revised the translation and added new material.
But who was Eosslin and what was the history of his work ?
Eucharius Eosslin, Eoslin, or Ehodian was a medical man
practising first in "Worms and then in Frankfort-on-Main.
The date of his birth is unknown, and for his death year two
dates have been given — 1526 and 1553. The earlier of the two
is most probably the correct one, the later date being that of
the death of his son. He published his work entitled Der
Swangern Frawen und Hebammen Rosegarten (by Imperial
Privilege) in 1513, and so gave to the world the first separate
work on midwifery. It was dedicated to Catherine, Princess
of Saxony and Duchess of Brunswick and Luneburg; and it
was a compilation from the works of Hippocrates, Galen,
Avicenna, Albertus Magnus, Aetius, Gordon, and Savonarola.
The earliest edition (that of 1513) had the same Birth Figures
as were found in Jonas and Eaynalde ; they were printed from
woodblocks. The work was divided into twelve chapters
corresponding to the First and Second Books of the Jonas
edition of the Byrth of Mankynde,. and (speaking generally) to
the Second and Third Books of the Eaynalde editions of the
same work. Several German editions of the Rosegarten
appeared (in 1522, 1529, 1571); then it was translated into
Latin, and, as De Partu Hominis, editions were brought out in
1532, 1535, 1536, 1537, 1538, 1551, 1554, 1556, and 1563 ;
Dutch translations, under the title of Den Rosegaert van den
bevruchten Vrouwen, came out in 1540, 1555, 1670, 1685, 1701,
and 1730; and there were French versions in 1536, 1540,
T
290
THE u BYKTH OF MANKYNDE,"
1563, and 1577. The English translations we have already
described.
In order that the reader may judge of the accuracy of the
Jonas and Kaynalde rendering of Ehodion's work, I place
here in parallel columns the Latin and the English of two
passages, one referring to the " Woman's Stoole " and the other
to Cesarean section : —
From Ehodion's "De Partu
Hominis."
From Raynalde's "Byrth of
Mankynde."
" Ad quam quidem rem, in qui-
busdam regionibus ut in Gallia et
Germania superiori, obstetrices
peculiaria sedilia habent, quae et
ab humo non non alte distant, et
excavata ita sunt, ut facile, quae
debent, transmittant, et reclinan-
tem tergo accipiant : quarum forma,
fere est talis, qualem hie adpinxi-
mus."
" At vero si diverso modo pariens
emoriatur inter enitendum, id quod
signis, quae morientes de se prae-
bent, facile deprehendi potest, et
partus in utero superstes, spem
vitae ostendat, principio convenit
morientis os, et infra genitalia cum
matrice aperta et reclusa servare,
quo per ea et vitalem spiritum
partus capere, et anhelitum recipro-
care possit, id quod mulieres medio-
criter peritae satis norunt. Deinde
reclinatae latus sinistrum recto
vulnere novacula incidi atque
" For the which purpose in some
regions (as in Fraunce and Ger-
many) the Midwyfes have stoles for
the nonce, whiche beynge but lowe,
and not hye -from the grounde, be
made so compasse wyse and cave
or holowe in the middes, that that
mai be receaved from underneth
which is looked for, and the backe
of the stole leaning backeward,
receaveth the back of the woman,
the fashion of the which stole, is
set in the beginning of the birth
figures hereafter."
" But contrary to all this, yf it
chance that the woman in her
labour dye, and the chylde havyng
lyfe in it : then shal it be meete
to kepe open the womans mouth,
and also the nether places ; so that
the chylde may by that means
both receave and also expell ayre
and breath, which otherwyse
myght be stopped, to the destruc-
tion of the chylde. And then to
turne her on the lefte syde, and
there to cut her open, and so to
take out the chylde. They that
BY DR J. W. BALLANTYNE. 291
aperiri (nam dexterum latus non be borne after this fashion are
ita liberum, propter hepar quod called Cesares, for because they be
in eo situm habet, ingressum in- cutte out of theyr mothers belly :
cidenti praebet) et inde partus whereupon also the noble Romayne
inserta manu per vulnus eximi Cesar the fyrste toke his name."
atque educi debet. Quo pacto qui
nascuntur, cesares dici solent, ut
etiam Romae ille a quo primo
cesarum familia nomen adepta
fuit, primusque caesar, eo quod
caesa est matre natus, appellatus,
est."
It will be seen that the translation is not strictly literal,
neither is it exact : for instance, the reason why the abdomen
(in Cesarean section) is to be opened on the left side rather than
on the right is given in the Latin version but does not appear
in the English. Possibly some divergences may be explained
on the supposition that Jonas and Raynalde used editions of
Be Partu Hominis which I have not been able to see.
I have now concluded my survey of this remarkable book —
The Byrth of Mankynde — both as regards its contents and in
respect to its authors and editions. Although its precepts may
bring a smile to the face of the obstetrician of the present day
and merit his contempt, yet it was the most potent factor in
establishing the popular customs which cluster round the
practice of midwifery in these Islands, customs which can be
traced and recognised even now.
Addenda et Corrigenda.
Since I wrote my article on the Author and Editions of the
Byrlh of Mankynde I have been informed of several other copies
of some of the editions, and have been led to alter some of the
statements made. For instance, I am doubtful of the existence
of an edition of 1676. Dr C. Napean Longridge, to whom I am
292 THE "BYRTH OF MANKYNDE," -
greatly indebted for a series of researches made for me in the
British Museum, finds that the so-called copy of 1676 named in
the catalogue of the Museum is really that of 1626. I have,
therefore, removed this edition from the list.
I have now had an opportunity of examining a copy of the
1604 edition. It belongs to Prof. H. E. Spencer, to whose kind-
ness I am indebted for the privilege of inspecting it. It is very
similar in all respects to the edition of 1598. The ornamental
title page is exactly the same, with the exception of a few
differences in the typography of the title. At the foot of the
inscription is, " Imprinted at London for Thomas Adams,"
instead of, "Imprinted at London by Eicharde Watkins,"
which appears in the 1598 edition. The colophon reads,
"Imprinted at London for Thomas Adams, 1604." There
are 204 pages in this edition, and three preliminary leaves ;
the plates are the same, although two plates of the " Byrthe
Fygures" happen to be missing in the copy which I am
describing; and .the type is black letter mostly. It would
seem, therefore, as if Watkins, the printer of the 1598 edition,
had assigned the blocks as well as the license for printing the
Byrth of Mankynde to Thomas Adams.
I must correct the statement made by me on p. 243 of
my former article (loc. cit.) about the ninth figure of the
Anatomical Plates. It does not make its first appearance in
the edition of 1560 ; it was present (as Figure 5) in the 1545
and 1552 editions. The altering of the order of description of
the figures in the 1560 issue had misled me.
Here follows the revised list of the editions. I may take
this opportunity of thanking Dr E. Wilson Gibson, of Orton,
Tebay, Westmorland, for kindly giving me a perfect copy of
the 1654 edition.
BY DR J. W. BALLANTYNB. 293
Summary of the Editions of the " Byrth of Marikynde."
Edition of 1540. Jonas's Translation of Eosslin. British
Museum.
Edition of 1545. Eaynalde's Translation. British Museum ;
Royal College of Physicians, London ; Hunterian Library,
University, Glasgow.
Edition of 1552. Eaynalde's Translation. Eoyal College of
Physicians, Edinburgh; London Obstetrical Society; Dr
W. Blair Bell, Liverpool.
Edition of 1560. Eaynalde's Translation. Eoyal College of
Surgeons, London; Dr J. W. Ballantyne, Edinburgh;
University of Aberdeen.
Edition of 1565. Eaynalde's Translation. British Museum;
University of Edinburgh; Eoyal College of Surgeons of
London; Washington Library; Hunterian Library,
University, Glasgow.
Edition of 1564 (?). Eaynalde's Translation. British Museum ;
University of Glasgow; Eoyal College of Physicians,
London ; Dr J. F. Payne, London.
Edition of 1593 (?). Eaynalde's Translation. Eadford Library,
Manchester.
Edition of 1598. Eaynalde's Translation. British Museum;
Eoyal Medico - Chirurgical Society of London ; Dr
C. E. Underhill; Washington Library; Hunterian
Library, University, Glasgow; Medical Institution, Liver-
pool.
Edition of 1604. Eaynalde's Translation. British Museum;
Washington Library ; Dr H. E. Spencer, London.
Edition of 1613. Eaynalde's Translation. Eoyal College of
Surgeons of London (2 copies).
Edition of 1626. Eaynalde's Translation. British Museum;
University of Edinburgh; London Obstetrical Society;
Faculty of Physicians and Surgeons of Glasgow.
294 THE "BYRTH OF MANKYNDE," BY DR J. W. BALLANTYNE.
Edition of 1634. Kaynalde's Translation. British Museum;
Koyal College of Physicians, London; London Obstetrical
Society ; Washington Library.
Edition of 1654. Kaynalde's Translation. British Museum;
Washington Library ; Dr W. L. Eeid, Glasgow ; Uni-
versity of Aberdeen ; Dr J. W. Ballantyne, Edinburgh.
INDEX
Abortion, case of repeated, due to
syphilis; treatment by potassium
iodide; birth of child with con-
genital goitre (Watson), 204.
Albuminuria, acute, caused by pres-
sure of tumour on both ureters
(Porter). 75.
B
Ballantyne, Dr J. W., gives inaugural
address, 3 ; reads paper, 236 ; shows
specimens, 120, 191, 221 • on Dr
Porter's paper, 81 ; on Dr Eliz.
Macdonald's paper, 116; on Dr
Haultain's paper, 131 ; on Sir
Halliday Croom's paper, 158; on
Professor Jardine's paper, 1 83 ; on
Dr Campbell's paper, 189; on Dr
Brewis's paper, 203 ; on Dr Watson's
paper, 218; on Professor Kynoch's
paper, 234.
Barbour, Dr Freeland, moves vote of
thanks, 2; reads paper, 136 ; shows
specimens, 121 ; on Dr Lackie's
paper, 33 ; on Dr Haultain's paper,
132 ; on Sir Halliday Croom's paper,
158; on Professor Kynoch's paper,
230.
Bilateral ovarian dermoid tumours
complicating pregnancy (Campbell),
184.
Brewis, Dr N. T., reads papers, 49,
191 ; shows specimens, 41, 140, 189 ;
295
on Dr Ferguson's paper, 65 ; on Dr
Haultain's paper, 133; on Sir
Halliday Croom's paper, 1 59 ; replies
to discussion, 57, 203.
"Byrth of Mankynde"; its contents
(Ballantyne), 236.
Cesarean section for contracted pelvis,
series of five cases of (Kynoch), 221.
Campbell, Dr Malcolm, reads paper,
184; replies to discussion, 189.
Cervical fibroids removed by ab-
dominal hysterectomy, a clinical
and anatomical study of thirty
cases of (Haultain), 121.
Church, Dr, on Dr Lackie's paper, 37 ;
on Sir Halliday Croom's paper, 162.
Croom, Professor Sir Halliday, reads
paper, 143; replies to discussion,
162.
I)
Dermoid tumours, bilateral ovarian
(Campbell), 184.
Dewar, Dr, on Dr Lackie's paper, 35.
E
Epilepsy and the status epilepticus in
connection with pregnancy and
labour (Jardine), 165.
296
INDEX.
Exophthalmic goitre in its relation to
Obstetrics and Gynaecology (Groom),
143.
Fellows, election of, Ordinary, 2, 41,
74, 120, 163 j Honorary, 220.
Ferguson, Dr Haig, reads paper, 57 ;
shows specimens, 45, 142, 163, 190;
on Dr Lackie's paper, 34 ; on Dr
Leary's paper, 74; on Professor
Jardine's paper, 182; on Dr Wat-
son's paper, 217; replies to discus-
sion, 66.
Fibroid tumours, complicating preg-
nancy, treated by hysterectomy
(Brewis), 49.
Fibroid tumours in pregnancy, hys-
terectomy for (Barbour), 136
Fordyce, Dr W., shows specimens, 164.
Future of Obstetrics, inaugural
address on the (Ballantyne), 3.
G
Goitre, congenital, birth of child with,
in case of repeated abortion, treated
by potassium iodide (Watson), 204.
Goitre, exophthalmic, in its relation
to Obstetrics and Gynaecology
(Croom), 143.
Haultain, Dr, reads paper, 121 ; shows
specimens, 48, 74, 164; on Dr
Porter's paper, 81 ; on Dr Eliz.
Macdonald's paper, 117; on Pro-
fessor Jardine's paper, 180; on Dr
Campbell's paper, 188.
Intractable uterine haemorrhage and
arteriosclerosis of uterine vessels
(Eliz. Macdonald), 83.
Jardine, Professor, reads paper, 165;
replies to discussion, 183,
Kerr, Dr Munro, on Professor Kynoch's
paper, 230.
Kynoch, Professor, reads paper, 221 ;
shows specimens, 220 ; on Dr
Porter's paper, 82 ; replies to dis-
cussion, 235.
Lackie, Dr Lamond, reads paper, 28 ;
on Dr Brewis's paper, 56 ; on Dr
Leary's paper, 73 ; on Professor
Kynoch's paper, 234 ; replies to
discussion, 40.
Leary, Dr Garnet, reads paper, 67.
M
Macdonald, Dr Eliz., reads paper, 83 ;
replies to discussion, 119.
N
Nicholson, Dr Oliphant, on Dr
Lackie's paper, 37 ; on Sir Halliday
Croom's paper, 160 ; on Dr Watsons
paper, 214.
O
Occipito-posterior cases, the manage-
ment of some difficult (Lackie), 28.
Office-bearers, election of, 2.
Paterson, Dr Keppie, on Dr Brewis's
paper, 57 ; on Dr Leary's paper, 72 ;
on Dr Watson's paper, 216.
Porter, Dr Fred., reads paper, 75 ; on
Dr Ferguson's paper, 66; on Dr
Eliz. Macdonald's paper, 119; on
Professor Jardine's paper, 183;
replies to discussion, 82.
Prognosis of pregnancy in patients
with one kidney, on the ; with
notes of an unusually complicated
case of labour after nephrectomy
(Haig Ferguson), 57,
INDEX.
297
Puerperal septicaemia, successful treat-
ment of, by antistreptococcic serum
(Leary), 67.
R
Kitchie, Dr James, moves vote of
thanks, 34 -shows specimens, 48;
on Dr Lackie's paper, 34 ; on Dr
Brewis's paper, 56; on Dr Fergu-
son's paper, 66 ; on Dr Porter's
paper, 82 ; on Dr Eliz. Macdonald's
paper, 1 1 8 ; on Sir Halliday Croom's
paper, 159 ; on Dr Watson's paper,
214 ; on Professor Kynoch's paper,
234.
Specimens, exhibition of, 41, 74, 120,
140, 163, 189, 220.
Simpson, Dr Barbour, shows medal,
48.
Treasurer, annual statement of, 1.
Vaginal Caesarean section, six cases
of (Brewis), 191.
W
Watson, Dr B. P., reads paper, 204
on Dr Eliz. Macdonald's paper, 119
on Sir Halliday Croom's paper, 162
replies to discussion, 219.
PR1NTKD BY
OLIVER AND BOYD,
EDINBURGH
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